Every finding on record at Creve Coeur Manor

Based on interview and record review, the facility failed to ensure staff assessed and monitored one resident (Resident #3) identified as at risk for developing pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). When staff from an outside hospice agency identified a new skin issue and notified the facility nurse, the nurse failed to document the notification and failed to notify the physician timely, resulting in a delay in treatment. Two residents were sampled for pressure ulcers and problems were found with one. The sample was 6. The census was 73.Review of the facility's Wound Management policy, dated 01/2023, showed the following:-Policy: Manage skin integrity through prevention, assessment, and implementation and evaluation of interventions;-Procedure:-The facility is provided with wound care protocols. These are to be utilized to assist in the care and treatment of wounds. These are to be utilized to assist in the care and treatment of wounds. This reference tool is placed in the nursing report books. Physician orders should be obtained and followed for each resident;-Residents at risk on the Braden Scale (clinical tool used to assess risk of developing pressure ulcers) will have this addressed on their care plan and will have interventions put in place for preventative measure. High risk or any Stage pressure injury will have skin checks daily;-The facility will assess all residents weekly for current skin conditions. Any resident that scores very high risk, high risk, or has a pressure injury present will have a skin check documented daily to identify any new or worsened areas. The daily skin assessment will be documented on the electronic treatment administration record (eTAR)/electronic medication administration record (eMAR), which is to be completed as follows:--Observe the skin for the following: clear, redness, open, pressure and skin tear. Weekly skin assessment will be documented on the skin observation in the electronic health record. Indicate the location of any identified areas. If any new areas are identified, write a nurse's note describing the area found and the protocol followed to treat it. Update wound management. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/16/26, showed the following:-Diagnoses included Alzheimer's disease, high blood pressure, and diabetes;-Short/long-term memory loss;-Required total staff assistance for all activities of daily living;-Incontinent of bowel and bladder;-At risk for pressure ulcers;-No pressure ulcers. Review of the resident's physician's order sheet (POS), showed an order, dated 04/03/26, to admit to hospice services. Review of the resident's Braden Scale, dated 04/08/26, showed a score of 11 (score of 10 to 12 equals high risk). Review of the resident's skin observations, showed:-On 04/30/26, no abnormalities noted;-No documentation of skin observations completed in May 2026. Review of the hospice company aide log, dated 05/27/26, showed the following:-Bed bath completed;-New wound on right buttocks;-Reported to the nurse, Licensed Practical Nurse (LPN) E. Review of resident's physician order sheet (POS) for May 2026, showed no physician order for treatment to the right buttocks. Review of the resident's eMAR for May 2026, showed:-An order, dated 01/31/26, for skin checks daily. Instruction: Document C for clear, R for redness, O for open, P for pressure, and S for skin tear;--Staff documented C for skin clear on 05/01/26, 05/02/26, 05/04/26 through 05/07/26, 05/09/26, 05/11/26, 05/14/26 through 05/20/26, 05/23/26 through 05/28/26, 05/30/26, and 05/31/26;--Staff documented O for open on 05/03/26, 05/08/26, 05/10/26, 05/12/26, 05/13/26, 05/21/26, and 05/29/26. Review of the resident's eMAR for June 2026 for skin checks, showed staff documented C for skin clear on 06/01/26 through 06/04/26, and 06/06/26. Review of the resident's progress notes, showed the following:-No documentation from 05/27/26 through 06/06/26 regarding the new wound to the right buttocks;-On 06/06/26 at 3:59 P.M., new pressure ulcer to the right buttock. Measured 3.7 centimeters (cm) by 2.1 cm. Physician notified. New order for triple antibiotic ointment (TAO) and cover with dry dressing.-On 06/08/26 at 12:46 P.M., a Nurse Practitioner (NP) note showed chief complaint of right buttock pressure injury. Per nursing notes, resident noted with a new open skin area to the right buttock, physician notified and new wound care order initiated. Small new open skin area to right buttock, per nursing notes, measuring 3.7 cm by 2.1 cm, unable to assess today - resident found sitting in the Broda (reclining) chair. Pressure ulcer, right buttock, unstageable (slough (soft dead tissue) or eschar (hard dry tissue) not stageable due to coverage of wound bed by slough and or eschar);-On 06/08/26 at 4:30 P.M., a nurse's note showed wound appearance noted to be inconsistent with the treatment ordered. Wound observed to the right ischial (lower/back part of the hip, supports the body when seated) with yellow and tan slough present to the wound bed, red tissue noted at the margins, and discoloration of surrounding tissue. Area reassessed and measurements obtained per facility protocol. During an interview on 07/06/26 at 1:06 P.M., Hospice Certified Nurse Aide (CNA) F said he/she took care of the resident on 05/27/26. It was his/her first time taking care of the resident. During the bed bath, he/she saw an area to the resident's right buttock. It appeared to look like a boil that all the fluid had come out. He/She reported it to LPN E, who assessed the area and said it was an old wound that had been through the healing process. LPN E applied a cream without a dressing. Hospice CNA F completed the resident's bath and applied the resident's brief. The skin area was visible outside the brief. During an interview on 07/02/26 at 3:00 P.M., LPN E said Hospice CNA F reported the resident had an open area to his/her right buttock on 05/27/26. He/She assessed wound and thought it was an old healing wound. He/She applied some cream the resident had in his/her drawer. He/She didn't measure it or document it the resident's progress notes. He/She did not notify the physician about the area. During an interview on 07/06/26 at 1:30 P.M., Hospice Registered Nurse (RN) G said he/she took care of the resident on 05/27/26. He/She arrived after Hospice CNA F saw the resident. RN G assessed the resident while the resident was seated in the Broda chair on 05/27/26, but RN G did not look at the resident's skin at that time. No one at the facility reported any changes in the resident's skin. The first time he/she was made aware of wound was on 06/09/26 by the facility. The pressure ulcer was a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present) pressure ulcer that measured 2.7 cm by 2.1 cm by 0.2 cm with yellow slough and a small amount of drainage. During an interview on 07/06/26 at 1:39 P.M., Hospice CNA H said he/she took care of the resident on 06/02/25 at 8:00 A.M. and 06/04/26 at 1:30 P.M. Each day he/she arrived, the resident was seated in his/her Broda chair. Hospice CNA H laid the resident down for a bed bath. The resident was usually wet and soiled with stool. The resident had a wound to his/her buttocks that had no dressing on it. Each time he/she saw the wound, it appeared worse than before like no one was caring for it. After the bath, Hospice CNA H applied cream to the groin area but not the wound because CNAs aren't supposed to treat wounds. During an interview on 07/01/26 at 2:31 P.M., the Director of Nurses (DON) said the resident's hospice company bathed the resident his/her three times per week. The facility staff provided daily care. She didn't know if hospice aides filled out shower sheets. Hospice aides documented their bathing completion in the hospice binder and reported changes to the nurse. During an interview on 07/02/26 at 3:45 P.M., the DON said she expected staff to report to the nurse any changes in the resident's skin. Nurses were to complete weekly skin assessments and document them in the medical record. She identified that nurses weren't completing skin assessments. She expected nurses to complete the daily skin checks accurately. She determined the hospice company began to have different nursing staff, and they failed to report changes to the facility. During an interview on 07/02/26 at 3:55 P.M., the Administrator said she expected staff to notify the charge nurse of any changes in the resident's skin. The nurse should assess the area, notify the DON, physician, and family, and document in the medical record. During an interview on 07/10/26 at 9:10 P.M., the Office Manager for the resident's physician's office said the physician expected to be notified of any changes in the resident's skin. 3065660

Based on observation, interview, and record review, the facility failed to ensure staff transcribed physician orders and administered medications as ordered for one resident (Resident #1) and to hold medication in accordance with parameters ordered by the physician for one resident (Resident #2). The sample was 3. The census was 79.Review of the facility's Physician's Orders policy, dated February 2020, showed the following:-Elements of the medication order: Name of the medication, strength of the medication, dosage, time or frequency of administration ,route of administration if other than oral, quantity or duration (length) of therapy, diagnosis or indication, medication allergy;-Documentation of the medication order:-1. The physician's new orders may be received on the admission Physician's Order Form, by telephone or handwritten on the Physician Order Sheet (POS). All drug orders received via transfer sheet must be verified by the attending physician and transcribed onto the POS;-2. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. The order is recorded on the physician order sheet, the Medication Administration Record (MAR) and the Treatment Administration Record (TAR);-3. The following steps are initiated to complete documentation: --Clarify the order;--Enter the orders on the medication order and fax to the pharmacy;--Transcribed newly prescribed medications on the MAR or TAR. 1. Review of Resident #1's medical record, showed the following:-readmission date of 02/16/26;-Diagnoses included high blood pressure, stroke, and heart failure. Review of the resident's POS, showed an order, dated 02/16/26, for bisoprolol fumarate (medication used to treat high blood pressure) 5 milligrams (mg), give 1/2 tablet per gastrostomy (a sterile tube surgically inserted through the abdomen into the stomach, used to provide nutrition, medication, and fluids) once daily. Review of the resident's MAR, dated 02/16/26 through 02/28/26, showed no order for bisoprolol fumarate. Review of the resident's MAR, dated 03/01/26 through 03/31/26, showed no order for bisoprolol fumarate. Review of the resident's MAR, dated 04/01/26 through 04/30/26, showed no order for bisoprolol fumarate. Review of the resident's progress notes, showed no documentation regarding the bisoprolol fumarate. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated, 04/16/26, showed the following:-Short and long term memory loss;-Total dependence for all activities of daily living (ADL). Review of the resident's care plan, in use at the time of survey, showed no documentation regarding high blood pressure medication. Review of the resident's MAR, dated 05/01/26 through 05/21/26, showed no order for bisoprolol fumarate. During an interview on 05/21/26 at 3:40 P.M., the Assistant Director of Nurses (ADON) said she had passed medications to the resident several times as the charge nurse and was unaware of the order for bisoprolol fumarate. During an interview on 05/21/26 at 3:41 P.M., the Director of Nurses (DON) said she had passed medications to the resident several times. She was unaware of the order for bisoprolol fumarate 5 mg once a day. She had never seen the medication on the medication cart. A problem occurred when the medication was ordered and transcribed. She expected all medications to be administered as ordered. During an interview on 05/21/26 at 3:42 P.M., the Administrator said upon admission, she expected all admission paperwork to be completed and reviewed for accuracy. She expected all medications to be administered as ordered. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following:-Diagnoses included high blood pressure, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and high cholesterol;-Alert and oriented to name and place. Review of the resident's care plan, updated 03/31/26, showed the following:-Problem: Risk for cardiovascular problems related to high blood pressure and high cholesterol;-Approaches: Monitor vital signs per protocol. Notify physician of changes. Observe for signs and symptoms of cardiovascular problems. Observe effectiveness of medications. Review of the resident's POS, showed an order, dated 01/07/26, for metoprolol succinate 50 mg by mouth once a day. Hold if systolic blood pressure (SBP) is less than 100. Hold if diastolic blood pressure (DBP) is less than 60 and hold if heart rate (HR) is less than 60. Review of the resident's MAR, dated 05/01/26 through 05/15/26, showed the following:-An order, dated 01/07/26, for metoprolol succinate 50 mg by mouth once a day. Hold if systolic blood pressure (SBP) is less than 100. Hold if diastolic blood pressure (DBP) is less than 60 and hold if heart rate (HR) is less than 60;-Heart rate on 05/01/26 through 05/06/26, 05/08/26 through 05/11/26, 05/14/26 through 05/17/26, and 05/19/26 through 05/21/26 documented as below 60. Staff documented metoprolol succinate administered on these dates;-No documentation the physician was notified of below parameter heart rates. Review of the resident's progress notes, dated 05/01/26 through 05/21/26, showed no documentation the physician was notified of the resident's below parameter heart rates. During an interview on 05/22/26 at 2:05 P.M., Certified Medication Technician (CMT) A said he/she worked the dayshift and had administered medication to the resident. He/She would hold the resident's blood pressure medication if the resident's heart rate was below the parameter. He/She didn't recall whether he/she notified the nurse of the resident's low heart rate. During an interview on 05/21/26 at 3:41 P.M., the DON said she expected the CMT to have notified the nurse of the resident's low heart rate. The nurse should have notified the physician and clarified the order. During an interview on 05/21/26 at 3:42 P.M., the Administrator said she expected physician orders to be followed as ordered. 2993902

Based on observation, interview and record review, the facility failed to ensure one resident received gastrostomy tube (g-tube, a sterile tube surgically inserted through the abdomen into the stomach, used to provide nutrition and fluids) feedings and fluids as ordered. The facility identified three residents with tube feedings, one of whom was sampled and problems were found (Resident #1). The census was 80.Review of the facility's Tube Feeding, policy, dated 3/28/25, showed the following:-Policy: It is the policy of the facility of the facility that residents' nutritional needs will be met by tube feeding, when oral consumption is not possible and the resident consents;-Procedure included:--Check the physician's order to determine type and rate of feeding;--Set the pump for the rate ordered;--Start the pump.Review of the facility's Obtaining and Following Physician Orders policy, dated 7/2017, showed the following:-Policy: It is the policy of the facility that physician orders will be obtained by licensed personnel and followed. If those orders are not followed for any reason, the physician and Director of Nurses (DON) will be promptly notified;-Procedure included:-When it is discovered that a physician's order was not implemented, the nurse shall immediately notify the physician of this failure and document the omission on an accident and incident form. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/14/25, showed the following:-Diagnoses included high blood pressure, stroke, and dementia;-Short and long-term memory loss;-Required total staff assistance for all activities of daily living (ADLs);-Feeding tube: Yes;-Received 51% or more of total calories and fluids per feeding tube. Review of the resident's care plan, updated 1/29/26, showed the following:-Problem: Resident at risk for alteration in nutrition and hydration related to (r/t) difficulty swallowing and history of failed swallow test;-Goal: Nutritional and weight will remain stable;-Approach: Diet as ordered. Monitor labs and weight;-Problem: Resident is at risk for complications related to g-tube;-Approaches: Provide tube feeding as ordered. Water flushes as ordered. Review of the resident's physician order sheet (POS), dated 3/2026, showed the following:-An order, dated 1/15/26, for tube feeding, Jevity 1.5 Cal (calorie dense, high protein, fiber fortified liquid formula), 45 milliliters (ml) per hour for 23 hours;-An order, dated 1/15/26, to flush g-tube with 150 ml of water every four hours. Observation on 3/2/26, showed the following: -At 10:38 A.M., the resident not in his/her room. Jevity 1.5 Cal and water hung on the pole next to the resident's bed;-At 10:48 A.M., the resident sat in the hallway across from the nurse's station without his/her tube feeding or water. Registered Nurse (RN) A sat at the nurse's station in full view of the resident;-At 1:45 P.M., the resident lay in bed. Jevity 1.5 Cal and water hung on the pole next to the resident's bed, not attached to the resident. During an interview, on 3/2/26 at 1:05 P.M., Certified Nurse Aide (CNA) B said he/she got the resident up at around 9:00 A.M. and placed him/her at the nurse's desk. During an interview, on 3/2/26 at 1:50 P.M., RN A said he/she was the charge nurse taking care of the resident. Staff brought the resident out to the nurse's station this morning around 9:00 A.M. When asked about the resident's tube feeding, RN A said it was ordered to begin this afternoon at 3:00 P.M. During the interview, RN A reviewed the resident's POS and said the resident's tube feeding should have been restarted once the resident was gotten out of bed. He/She would notify the physician of the error. During an interview on 3/2/26 at 2:25 P.M., the DON said she expected nurses to follow the resident's tube feeding orders as written. The nurse should be aware of the residents on his/her floor with tube feedings and what their orders are. During an interview on 3/2/26 at 2:30 P.M., the Administrator said she expected the nurse to infuse the resident's tube feeding as ordered.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS)), for four residents who required EBP for wound treatment or a medically inserted device (urinary catheter, a sterile tube inserted into the bladder through the urinary tract to drain urine). The facility identified eleven residents requiring EBP, four residents were sampled and problems were found with all four residents (Residents #1, #2, #4, and #5). The census was 77. Review of the facility's Isolation Precautions/Enhanced Barrier Precaution (EBP) policy, dated, 4/2/24, showed: -Policy: It is the policy of the facility to make every effort to prevent the spread of infection in the facility. Standard Precautions require the health care worker (HCW) to estimate the degree of risk associated with a given task and plan for appropriate personal protective equipment. Enhanced Barrier Precautions is used in combination with Standard Precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; -Procedure:EBP will be used for any resident who meets the following criteria: -Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. -Chronic wounds, such as, pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence), venous stasis ulcers (ulcers caused by decreased blood circulation), diabetic ulcers (ulcers caused by decreased blood circulation), -unhealed surgical wounds; -Indwelling medical devices, such as, central lines (a long, flexible tube your provider inserts into a vein in your neck, chest, arm or groin for administration of blood, medications or dialysis), urinary catheters, feeding tubes (g-tube, a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications), and tracheostomies (tube surgically inserted into the trachea for the purpose of breathing); -Residents who meet the above criteria, EBP are recommended when performing the following high-contact resident care activities: -Dressing; -Providing hygiene; -Bathing/showering; -Transferring; -Changing linens; -Changing briefs or assisting with toileting; -Indwelling medical devices care; -Chronic wound care; -Place EBP sign at entrance to the room for the resident who meets the criteria; -Staff will clean their hands before entering and when leaving the room; -Staff will wear gloves and a gown for High-Contact Resident Care Activities; -Do not wear the same gloves and gown for the care of more than one person; -If only one resident in the room requires EBP, place an EBP sign above the bed of the resident who meets the criteria as well as the entrance to the room. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/31/25, showed: -Cognitively intact; -Dependent on staff for toileting, positioning and transfers; -Indwelling urinary catheter; -Three Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcers present on admission. Review of the resident's care plan dated 5/8/25, showed: -Problem: Resident requires enhanced barrier precautions; -Goal: Resident will receive care from staff using EBP while maintaining a homelike environment, and will remain free from infections through next review; -Approaches: Enhanced barrier precautions will be utilized while providing direct care. (ex. wound dressing changes, showers/bathing, transfers, hygiene, linen changes, toileting assistance, during therapy, device care). Staff will don gown and gloves prior to entering room to perform care. EBP to be removed prior to leaving room. Review of the resident's June 2025 electronic Physician's Order Sheet (ePOS), showed: -An order for indwelling urinary catheter, assess and monitor and empty each shift; -An order to cleanse wound with wound cleanser and apply Medi honey (an ointment to aid in the healing of wounds) to wound bed daily and as needed; -No physician order for EBP. Observation on 6/4/25 at 10:37 A.M., showed an EBP sign on or by the resident's door. No PPE cart or equipment was visibly available for staff to use. Certified Nurse Aide (CNA) C was in the resident's room with CNA D, providing morning care to the resident. CNA C emptied the resident's catheter bag and provided perineal (cleaning of the groin and buttocks) care. CNA D assisted the resident with getting dressed. Both staff used a mechanical lift to transfer the resident from his/her bed to a wheelchair. Both staff wore gloves but neither staff wore a gown. During an interview on 6/4/25 at 10:30 A.M., CNA C and CNA D said they should have been wearing gowns while providing care to Resident #1. The facility did not provide additional PPE for residents on EBP. 2. Review of Resident #2's admission MDS, dated [DATE], showed: -Cognitively intact; -Has indwelling catheter; -Colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall for the elimination of feces); -Risk of pressure ulcers; -Three Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcers, present on admission. Review of the resident's June 2025 ePOS, showed: -Dakin's Solution (sodium hypochlorite) solution; 0.125 %; (topical antiseptic used to treat and prevent infections from wounds); -Clean left gluteal (buttocks) region with wound cleaner or normal saline. Lightly pack with Dakin's moistened gauze. Apply dry dressing and secure with tape. Change daily; -Clean right gluteal region with wound cleaner or normal saline. Lightly pack with Dakin's; -Clean gluteal cleft region with wound cleaner or normal saline. Lightly pack with Dakin's moistened gauze. Apply dry dressing and secure with tape. Change daily; -Clean left ischium (lower portion of the hip bone) region with wound cleaner or normal saline. Lightly pack with Dakin's moistened gauze. Apply dry dressing and secure with tape. Change daily; -Clean right ischium region with wound cleaner or normal saline. Lightly pack with Dakin's moistened gauze. Apply dry dressing and secure with tape. Change daily; -Clean coccyx (tailbone) region with wound cleaner or normal saline. Lightly pack with Dakin's moistened gauze. Apply dry dressing and secure with tape. Change daily. -Indwelling Catheter: -Empty catheter bag every shift. Monitor for hematuria (blood in the urine), changes in color, consistency and odor every shift. Notify physician of changes; -Provide catheter care every shift; -Shower twice weekly on Wednesday and Saturday evening; -No physician order for EBP. Review of the resident's care plan dated 3/17/25, showed staff did not address the need for EBP. Observation and interview on 6/4/25 at 7:32 AM, showed Registered Nurse (RN) A and RN B entered the resident's room. There was no EBP signage on the door or wall adjacent to the resident's room. There was no visible PPE cart or PPE supplies observed. RN A assisted RN B in providing wound treatments to the resident. Both staff wore gloves but no gowns. RN A touched and moved the indwelling catheter when repositioning the resident. 3. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Dependent on staff for positioning, transfers, toileting hygiene, and showers/baths; -Indwelling urinary catheter; -Colostomy; -One Stage IV pressure ulcer present on admission; -Wound infection; -Intravenously (IV, administered into a vein) medications while a resident. Review of the resident's care plan, dated 4/25/25, showed: -Problem: Resident requires Enhanced Barrier Precautions related to wounds and use of Foley catheter; -Goal: Resident will receive care from staff using EBP while maintaining a homelike environment; -Approach: Staff do not need to use EBP if they are not engaging in high contact resident care: giving medication, conversing with resident, answering call light. Staff to use EBP while providing the following care: Wound dressing changes, showers/bathing, transfers, providing hygiene, changing of linens, toileting assistance/changing of briefs, providing therapies, device care or use, receiving therapies. Staff will don gown and gloves prior to entering room to perform care. EBP to be removed prior to leaving room. Staff will wash hands or use hand sanitizer prior to entering room and when leaving room. Review of the resident's June 2025 ePOS, showed: -#20 French (size of catheter tubing) Foley catheter with 10 millimeters (ml) balloon, monthly using sterile technique once on Wednesday every four weeks; -Dakins Solution: Clean wound to right buttock with wound cleaner. Pack with moistened Dakins dressing and then dry dressing packed on top. Cover with bordered dressing and secure with tape. Change daily. -Enhanced Barrier Precautions: Special Instructions: EBP for wounds, ostomy and catheter. Observation on 6/4/25 at 7:05 AM, showed RN A and RN B entered the resident's room. There was EBP signage on the door or wall adjacent to the resident's room. There was no visible PPE cart or PPE supplies observed. RN A assisted RN B in providing wound treatments to the resident. Both staff wore gloves but no gowns. RN A touched and moved the indwelling catheter when repositioning the resident. 4. Review of Resident #5's care plan dated 5/19/25, showed staff did not address the resident's pressure ulcer or the need for EBP. Review of the resident's 5-day MDS, dated [DATE], showed: -Moderately impaired cognition; -Recent fracture; -Risk of pressure ulcers; -Antibiotics provided. Review of the resident's June 2025 ePOS, showed: -Left heel: Clean with wound cleaner, apply betadine (a topical antiseptic), wrap with gauze or apply border gauze. Change daily and as needed; -No orders for EBP. Observation and interview on 6/4/25 at 7:32 AM, showed RN A and RN B entered the resident's room. There was EBP signage on the door or wall adjacent to the resident's room. There was no visible PPE cart or PPE supplies. RN A assisted RN B in providing wound treatments to the resident. Both staff wore gloves but no gowns. RN A touched and moved the indwelling catheter when repositioning the resident. 5. During an interview on 6/4/25 at 8:30 A.M., RN A and RN B said they should have been wearing gowns while providing wound care. The facility did not supply enough PPE carts and supplies for residents requiring EBP. 6. During an interview on 6/4/25 at 2:51 P.M., the Assistant Director of Nursing (ADON) said there should be EBP signs on the resident doors who had wounds, open areas and catheters. Staff should wear PPE when providing care to residents on EBP. Staff did not need to wear PPE if they would not be in close contact with residents or would not be in the room more than 15 minutes. She expected staff to wear PPE appropriately. There should be an EBP sign on the doors and PPE equipment available for each room. At this time, the facility did not have enough PPE carts and/or PPE supplies. 7. During an interview on 6/4/25 at 2:59 P.M., the Regional Nurse Manager said she expected staff to wear PPE while providing care to residents on EBP. EBP signs should be posted on or near the resident's room. There should always be enough PPE to meet the needs of the residents requiring EBP.

Based on review of menus, policy review, observations and interviews, the facility failed to ensure that menus were followed for all four days of the survey. The deficient practice has the potential to affect all 69 residents that receive food from dietary. Findings include: Observation of the first-floor food service on 11/13/24 at 12:40 PM revealed Dietary Aide (DA) 1 used a three ounces ladle to serve residents winter vegetables from the steam table. The menu/spreadsheet indicated that four ounces of vegetables. In addition, staff had no way to measure double portions of six ounces or single portions of three ounces of pot roast. Interview with DA1 at the time of the observation stated the cards provided do not have portion sizes or menus are not available. She stated that for the meat, I simply use my eyes and serving tongs to decide how much meat is to be provided. Observations of the first-floor food service on 11/13/24 at 12:40 PM revealed that DA1 served all nine mechanical soft diets whole pieces of pot roast, winter vegetables and scalloped potatoes. The menu indicated for these nine diets, mechanical soft to receive chopped meat, vegetables, and potatoes. The steamed winter blend vegetables made up of broccoli and cauliflower and scalloped potatoes were served not chopped. A dinner roll was indicated on the menu to be served to each resident however, no dinner rolls were served to any of the residents. Interview with the Dietary Manager (DM) on 11/13/24 at -11:45 AM, he stated he felt the items were soft enough and did not need to be chopped for that reason and verified he did not serve the dinner rolls at lunch on 11/13/24. The DM was asked for a policy and did not provide the policy prior to the survey team's exit from the facility.

Based on observations, document review, policy review and interview, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards of practice including dishwasher sanitizing, cleaning, food storage and handling and processing food for serving. The deficient practice has the potential to affect all 69 residents receiving food from dietary. Findings include: Observation on 11/11/24 at 9:47 AM revealed the temperature gauge on the dishwasher was stuck at 105 degrees Fahrenheit (F). The dishwasher was a low temperature machine and relies on sanitizer to sanitize the dishes during the final rinse. The machine specifics located on the side of the machine via label indicate for machines using sanitizer solutions to sanitize dishes, wash, rinse and sanitize water shall be minimum 120 degrees F. The facility continued to wash and distribute dishes. Interview with the Dietary Manager (DM) at the time of the observation verified the temperature gauge problems. Observation on 11/11/24 at 9:50 AM revealed two ducted wall air vents near the steamer and window, had a heavy accumulation of dust and dirt to the point of hanging off the vent. In addition, the window at the steamer was severely cracked and damaged over four feet in length with large amounts of dust, and cobweb debris at the inside and outside of the window. One walk-in freezer with the door removed used as permanent storage was found on 11/11/24 at 9:55 AM to have two dirty mopheads on the floor, red tile floor turned black with dirt, used cups, cleaning solutions, gloves, bags and food debris on the floor. Interview with the DM at the time of the observation verified the findings and indicated he does not have a cleaning schedule for the kitchen, or any other area related to food service. On 11/11/24 at 10:05 AM, DA3 was observed loading dirty dishes and unloading clean dishes from the dishwasher without changing gloves. DA1 was observed on 11/12/24 at 9:45 AM to be loading dirty dishes and unloading clean dishes without changing the gloves. In all cases, the dishes were stacked and sent back into circulation at mealtime. Interview with the DM at the time of the dish machine observation, verified the process and stated Observation on 11/13/24 at 9:45AM, the dry storage area and back corridor of the kitchen have red tile floors that were black with dirt and grease. The dry storage area also had black floors with a 25-pound bag of Chinese breadcrumbs and a cardboard box of 192 English muffins on the floor. Observation on 11/13/24 at 9:50 AM revealed the Midea refrigerator with a six-pound container of [NAME] pears opened and uncovered. Interview with the DM at the time of the observation verified the open can was opened yesterday and the floors in the dry storage area have not been cleaned. Observation on 11/13/24 at 10:15 AM the microwave in the kitchen had a large amount of red food splashes inside at the top of the device. In addition, the device had no rotation plate to ensure food was cooked on all sides when microwaved. Interview with the DM at the time of the observation verified the condition of the microwave. Observation of the refrigerator on the first-floor kitchenette used by residents on 11/13/24 at 10:30 AM revealed four-by-four inch styro-foam containers with an unidentified molded food item appearing to be gray and black with fur. No date or label was noted on any container. three compartment styro-foam device contained smoke house fried chicken and mashed potatoes dated 09/23/24 and another container with chicken, mashed potatoes with gravy and green beans dated 11/03/24. In addition, a five-inch birthday cake was found in a bag with icing and a sale by date of 09/14/24. Finally, two mighty shakes were in the same refrigerator with no thaw dates. Interview with the Administrator on 11/13/24 at 10:55 AM verified all the contents. Observation on 11/13/24 from 11:05 AM to 12:45 PM, a large four-pound pre-cooked pot roast still packaged was observed on the counter at room temperature without refrigeration or cooling. Interview with the DM at the time of the observation indicated somebody forgot about the pot roast. Review of the facility' Registered Dietician (RD) report titled Consultant Dietician Report dated 10/16/24 submitted to the facility administration indicated multiple food items were noted to be uncovered and undated in the stainless-steel refrigerator. Walls throughout the facility need good cleaning. Review of the facility's policy titled Food Labeling, Date and Time dated January 2012 revealed the food item shall be labeled with the date and time of preparation. Review of the facility's policy titled Machine Ware Washing dated January 2012 revealed the dish machine washing temperature will be 120 F. and rinse temperature of 75-120 degrees F. No reference was made to sanitize rinsing. The policy also required logging temperatures for purposes of monitoring temperatures. There was no reference in the policy to changing gloves when using the dishwasher and working from dirty to stacking clean dishes.

Based on observations and interview, the facility failed to ensure that it maintained essential equipment in working condition. Specifically, the large walk-in refrigerator has been inoperable for over three months. The deficient practice has the potential to affect all 69 residents that receive food from dietary. Findings include: Observation on 11/11/24 at 9:35AM revealed a 15' foot deep by 10' foot wide walk-in refrigerator in dietary that was empty of refrigerated food items. Interview with the Dietary Manager at the time of the observation indicated the large walk-in refrigerator has not worked since July of 2024. Interview with the Administrator on 11/11/24 at 10:20 AM provided an estimate to replace the refrigerator compressor.

Based on job description review and interview, the facility failed to ensure that the Dietary Manager (DM) met minimum qualifications when a Registered Dietician (RD) was not employed full time at the facility. The deficient practice has the potential to affect all 69 residents who receive food from dietary. Findings include: Interview with the Dietary Manager (DM) on 11/11/24 at 9:40 AM, revealed he stated that he is not certified as a DM. Interview with the RD on 11/14/24 at 10:50 AM, revealed that she was at the facility eight hours a day one day a month. She stated she was responsible for the clinical aspects of the facility and advised the facility through reports of sanitation and food service. The RD stated that she was aware that the DM was not certified. Interview with the Administrator on 11/12/24 at 11:30 AM revealed she was aware of the lack of training when he accepted the job. We thought we could finish the training prior to the survey. Review of the facility job description titled Job Description-Dietary Manager undated indicated the qualifications for the job on the last page include a certificate for dietary manager as a minimum qualification.

Based on observations and interviews, the facility failed to use the services of a registered nurse on duty at least eight hours daily. The RN passing medications on dates listed below was also serving as the Director of Nursing while the facility had an average daily occupancy of 68 residents. Findings include: Review of the resident census list provided by the administrator dated 11/12/24 revealed the occupancy was 69 residents in house, on 11/13/24 revealed 69 residents in house and on 11/14/24 revealed 68 residents in house. Observations on 11/12/24 at 10:15 AM, 11/13/24 at 2:30 PM, and 11/14/24 at 09:30 AM, the Director of Nursing (DON) was working as the charge nurse administering medications to residents while working in the capacity of the DON. According to the nurse schedule dated 11/01/24 through 11/14/24, provided by the Administrator, seven of fourteen days did not have RN coverage for eight consecutive hours a day, The following days did not have RN coverage at least eight consecutive hours a day on 11/01/24, 11/05/24. 11/06/24. 11/07/24, 11/08/24, 11/12/24, and 11/13/24. During an interview with the Administrator and the DON, on 11/14/24 at 5:26 PM, the DON stated that she had been working as the DON and as the charge nurse as needed because staffing has been an ongoing issue for several months. The Administrator stated she was not aware that the DON could not serve as the RN on duty while working as the DON.

Based on observations, review of policy and interview, the facility failed to ensure the area around the garbage dumpster area was free of trash on four of four days of the survey. The deficient practice has the potential to affect all 69 residents. Findings include: Observations on 11/11/24 at 10:00 AM revealed the exterior garbage dumpster area had two dumpsters and the area around the dumpster had one college size broken pink refrigerator, numerous plastic gloves, food debris, numerous small and large cups for medicine, numerous fast-food bags, 10 cardboard boxes in various conditions, bottles of over-the-counter medicine, splatters of garbage, paper towels, plastic bags. Observations on 11/12/24 at 8:00 AM, 10:20 AM, 5:00 PM, 11/13/24 at 7:45 AM and 5:00 PM and 11/14/24 at 8:00 AM and 7:00 PM, revealed one of the dumpsters was noted to have the lid open. Interview with the Administrator on 11/12/24 at 10:20 AM revealed that housekeeping and maintenance maintain the area by cleaning it once a week. She stated she has no documentation related to when the area was cleaned. The Administrator provided a policy that indicated that the maintenance department was responsible for ensuring the exterior garbage area was free of trash and the lids were kept closed.

Based on interview and record review, the facility failed to follow their tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) policy when staff failed to complete a two step and the annual one step of the employee TB screening tests in a timely manner for a total of five employees. The census was 74. Review of the facility's Tuberculosis Policy, dated 2005, showed the following; -Tuberculosis (TB) Screening - Employees -It is the policy of this facility that all healthcare workers will undergo testing for tuberculosis upon hire. Initial testing will be completed using the two-step tuberculin skin test (TST) procedure. The first dose being administered within seven days after being employed and the second dose administered one to three weeks after the first test, if the first test is negative. 1. Review of Staff Member A's employee file, showed the following: -Hire date: 10/1/22; -No documentation of an annual one step. 2. Review of Staff Member B's employee file, showed the following: -Hire date: 7/18/23; -No documentation of an annual one step. 3. Review of Staff Member C's employee file, showed the following: -Hire date: 2/22/24; -No documentation of a two step. 4. Review of Staff Member D's employee file, showed the following: -Hire date: 3/7/24; -No documentation of a two step. 5. Review of Staff Member E's employee file, showed the following: -Hire date: 9/12/24; -No documentation of a two step. 6. During an interview on 11/20/24 at 1:17 P.M., the Administrator said after the Director of Nursing (DON) or the Assistant Director of Nursing (ADON), have administered the TB test, the Human Resource Manager (HRM) should follow up to ensure both steps are completed and the documentation is in the employee's file. The administrator said she would expect the TB policy to be followed. The DON and HRM are out sick today.

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three residents who expired and had money in their accounts (Residents #104, #107 and #106). In addition, the facility failed to provide notification when the resident's trust account reached $200 less than the Supplemental Security Income (SSI) resource for four residents (Resident #7, #101, #102, #105). The facility held funds for 51 residents. The census was 74. Review of the facility Resident's Rights Policy, undated, showed the following: -Notice of certain balances: The facility must notify each resident that received Medicaid benefits: -When the amount in the resident's account reaches $200 less than the SSI resource limit for one person; -That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI -Conveyance upon discharge, eviction, or death. Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law. 1. Review of Resident #104's medical record, showed the following: -Expired on [DATE]; -Ending balance of $4771.87; -No TPL was completed. 2. Review of Resident #107's medical record, showed the following: -Expired on [DATE]; -Ending balance of $5833.00; -No TPL was completed. 3. Review of Resident #106's medical record, showed the following: -Expired on [DATE]; -Ending balance of $610.61 4. Review of the facility Resident Trust Fund Statements, dated [DATE] through [DATE], Statement dated [DATE], showed the following: -Resident #7, [DATE], ending balance $6407.28; -No documentation of Medicaid Resident Fund Notification. -Resident #101, [DATE], ending balance $6196.57; -No documentation of Medicaid Resident Fund Notification. -Resident #102, [DATE], ending balance $6576.08; -No documentation of Medicaid Resident Fund Notification. -Resident #105, [DATE], ending balance $10,357.35; -No documentation of Medicaid Resident Fund Notification. 5. During an interview on [DATE] at 12:14 P.M., the Administrator said TPL and Resident Fund notifications have not been completed. The Administrator said she was just learning these needed to be completed. The Administrator said the Business Office Manager (BOM) is responsible for these tasks, but he/she has only been here since [DATE]. The BOM is still working on various tasks.

Based on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry for seven staff members. A sample of 10 employees hired were reviewed. The facility hired at least 100 new employees since the last survey. The census was 74. Review of the facility's Abuse Prevention Program, dated 9/29/22, showed the following: -Procedures for Prevention -Pre-employment Screening of Potential Employees: This facility will not knowingly employ any individual convicted of resident abuse, neglect, or misappropriation of property. The facility will not knowingly employ any direct care staff convicted of any of the crimes listed in the State Healthcare Worker Background Check Act (unless waivered under the provision of the Act), or with findings of abuse listed on the State CNA Registry. The facility will not knowingly employ any licensed staff that have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Prior to a new employee starting a working schedule, this facility will: a. Initiate a reference check from previous employers in accordance with facility policy; b. Obtain a copy of the state license of any individual being hired for a position requiring professional license; c. Check the Missouri CNA Registry on any individual being hired for prior to reports of abuse, previous fingerprint check results, and the sex offender website links on the registry. 1. Review of Housekeeper (Hsk) A's employee file, showed the following: -Hire date: 10/1/22; -No CNA registry check performed. 2. Review of Activity Director B's employee file, showed the following: -Hire date: 7/18/23; -No CNA registry check performed. 3. Review of Hsk C's employee file, showed the following: -Hire date: 4/29/24; -No CNA registry check performed. 4. Review of Hsk D's employee file, showed the following: -Hire date: 7/17/24; -No CNA registry check performed. 5. Review of Dietary Aide (DA) E's employee file, showed the following: -Hire date: 8/25/24; -No CNA registry check performed. 6. Review of Maintenance Director F's employee file, showed the following: -Hire date: 9/12/24; -No CNA registry check performed. 7. Review of Medical Record G's employee file, showed the following: -Hire date: 10/9/24; -No CNA registry check performed. 8. During an interview on 11/20/24 at 1:11 P.M., the Administrator said the Business Office Manager (BOM), who is also in charge of Human Resources (HR), should have been checking the CNA registry. The administrator said she spoke with the BOM/HR and he/she said he/she was never trained to check the CNA registry for non nursing staff. The BOM/HR person is out sick.

Based on observations and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one of two floors, (the secured second floor) affecting the 30 residents of the second floor. Specifically, the facility failed to maintain an environment free of food splatters on the walls, missing ceiling tiles, functioning door handles, holes in bedroom walls, holes in bathroom walls, unclean surfaces of tables, bathroom tiles, and clean equipment for the ice container creating an unpleasant environment for the residents. Findings include: During an initial tour of the second floor secured unit on 11/11/24 from 10:45 AM to 12:45 PM, the following concerns were observed and discussed with the Administrator, Maintenance Director (MD), and the Housekeeping Supervisor on 11/14/24 beginning at 09:49 AM. The dining room: The four of four tables were marred, scarred, had peeling purple paint, and had uncleanable surfaces. The walls had spills that had run down and were dried. The ice chest was dirty on the outside. The ice chest cart had a heavy buildup of dirt, grime, and food spills. The ice scoop was placed next to the ice chest uncovered. The window tracks had a black substance in the tracks. The planter on top of a half wall had food particles and debris inside. The half wall was marred, dirty, and had dried drips down the side. Interview with certified nursing assistant (CNA15) who worked on the second floor secured unit stated, it's always been like this, the tables especially. room [ROOM NUMBER]: The window blinds were broken. There was a missing drawer in the wardrobe. There was no handle on the bathroom door. The inside of the handle mechanism was exposed and observed with dirt and brown matter on the metal. The bathroom could not be accessed from room [ROOM NUMBER]. room [ROOM NUMBER]: There was no privacy curtain for bed A. The bathroom door was marred. There was wall damage behind the toilet and sink. The bathroom tiles had been painted and appeared to be dripping. The wall tiles had not been cleaned of the damaged paint. room [ROOM NUMBER]: There was a gap around the air conditioning unit under the window. The gap allowed one to see outside which would allow for cold or hot air and pests/bugs to enter the room. There was wall damage in the bathroom. The drawer that was observed on 11/11/24 was pulled out. The latex glove stuck in a large circle of dried brown liquid remained in the drawer. The tiles in the bathroom had been painted, appeared to be dripping, and had not been cleaned. room [ROOM NUMBER]: The metal vent fan, located directly above the toilet, was falling out of the ceiling. Approximately five inches of the metal fan was exposed. The were ceiling tiles missing around the vent. The bathroom tiles had been painted, appeared to be dripping, and had not been cleaned. There was wall damage by the dresser and behind the headboard of the bed. room [ROOM NUMBER]: There was wall damage in the bathroom which measured 12 inches across by 3 feet high exposing the wall supports and pipes. The bathroom door was stuck, very difficult to open. There were ceiling tiles missing in the bathroom. room [ROOM NUMBER]: There was a heavy layer of dust and dirt on air conditioning unit, the windowsill and towel dispenser in the bathroom. The resident stated, they don't clean my room. room [ROOM NUMBER]: There were no bedside tables for either resident in the room. Bed A had 1/2 cup of juice on the floor next to the bed and a cup of water on the floor. There was damage behind the headboards of bed A and bed B which measured 12 inches across. room [ROOM NUMBER]: There were pieces of floor tiles missing around the front of the toilet. There was wall damage on the corner of the wall under the window, approximately two by three inches. The face of the air conditioning unit was coming off. CLEAN LINEN ROOM: There was no doorknob on the door. A hole was where the doorknob should have been. There were ceiling tiles missing, approximately 6 feet by 3 feet which exposed the duct work, wires, and pipes. The MD said he was unaware of the concern. room [ROOM NUMBER]: There were two missing ceiling tiles. room [ROOM NUMBER]: There was a large, two feet by one foot ceiling tile missing above the wardrobe which exposed the duct work. The window blinds were broken. There was wall damage near the bed, approximately six inches in length. The light above the bed flickered continuously. There was a 4 foot by 2 foot area of drywall that had been patched. The bottom section approximately 2 feet across was not patches and which exposed wires. Pieces of floor tiles in the bathroom were broken and missing. room [ROOM NUMBER]: There was wall damage in the bathroom between the sink and the toilet, approximately two feet by one foot. room [ROOM NUMBER]: There was wall damage in the room behind the bed, approximately twelve inches in length. There were two ceiling tiles missing in the bathroom. There were brown stains around the base of the toilet. Pieces of floor tiles were missing in the bathroom around the toilet. room [ROOM NUMBER]: The door handle into the room was difficult to use as it went around too far before unlatching the door. There was an approximate 6 inch hole in the wall behind the door. The air conditioning unit cover was coming off. The wall tiles in the bathroom had been painted, appeared to be dripping, and had not been cleaned. room [ROOM NUMBER]: There were three ceiling tiles missing in the bedroom. The air conditioning unit cover was coming off. room [ROOM NUMBER]: The room was not occupied. There was a pillow, without a pillowcase, which had brown matter all across the pillow. The pillow was on top of an unmade bed. The floor was dirty. The bathroom door was scarred and chipped. The bathroom wall had an approximate 3 1/2 feet hole in the wall which exposed pipes and rubble. A 9 inch by 12 inch area of wall also exposed pipes. room [ROOM NUMBER]: The room was unoccupied. The window blinds were broken. There were broken ceiling tiles. There were holes in the wall behind the beds. The painted tiles, around the sink down to the floor, in the bathroom were peeling and not clean. During an interview on 11/14/24 at 10:59 AM, the Administrator said she was unaware of the conditions identified on the tour. The MD said he was unaware of the conditions identified. When asked what type of communication system was in place for staff to alert the MD of needed repairs, he said he did not have a system in place. The Administrator said the windows had already been identified that they need cleaning and fix. The Administrator was asked to show the plan including what was involved, how it was to be accomplished, and the time frame for correcting the concern. The Administrator provided no documentation prior to the exit on 11/14/24 at 7:00 PM. MO00244495

Based on observations, record review and interviews, the facility failed to ensure that diets provided were prepared and distributed as prescribed by the residents' physician for seven residents (R12, R43, R35, R171, R50, R4 and R26 ) out of 26 residents in the sample. The deficient practice has the potential for residents to lose weight. Findings include: 1. Review of R12's Face sheet in the electronic medical record (EMR) under the profile tab revealed diagnoses of Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, cerebral infarction, type 2 diabetes without complications, abnormal weight loss and pressure ulcer, sacral region stage 2. Review of R12's physician orders in the EMR under the orders tab revealed an order for a pureed diet, power potatoes for lunch, cheesy eggs for breakfast, ice cream for snacks, health shakes at each meal, whole milk at breakfast and apple or cranberry juice for lunch and dinner. Observations on 11/11/24 at 12:30 PM; 11/12/24 at 8:30 AM; 11/12/24 at 12:45 PM and on 11/13/24 at 12:35 PM revealed the resident failed to receive a diet as prescribed by the physician which included power potatoes for lunch on 11/11/24, 11/12/24 and 11/13/24; cheesy eggs on 11/12/24 and health shakes on 11/11/24 and 11/12/24. Interview with the Dietary Manager (DM) on 11/13/24 at 1:30 PM revealed he did not prepare or serve cheesy eggs or power potatoes all week starting 11/11/24 through 11/13/24; health shakes on 11/11/24 and on 11/12/24. 2. Review of R43's EMR revealed under the profile tab diagnoses of traumatic subdural hematoma without loss of consciousness, dementia, mood disturbance, psychotic disturbance, Parkinsonism, post-traumatic stress disorder, anxiety disorder, depression, anxiety disorder and anorexia. Review of R43's physician orders under the orders: tab in the EMR revealed regular diet and health shakes three times a day or with each meal. Observations on 11/11/24 at 12:30 PM and 11/12/24 at breakfast at 8:30 AM revealed that R43 did not receive health shakes. The facility did not order the health shakes from the supplier until the problem was pointed to the facility at lunch on 11/12/24. Interview with the DM on 11/13/24 at 1:30 PM revealed he did not prepare health shakes for 11/11/24, 11/12/24, and 11/13/24. Interview with the Registered Dietician (RD) on 11/14/24 at 10:50 AM, the RD stated that all diets should be followed as prescribed by the physician. She was not aware that power potatoes, cheesy eggs and health shakes were not being provided. 3. Review of R35's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnoses that included cerebral palsy, generalized anxiety disorder, mood disorder, conversion disorder with seizures or convulsions, dysphagia, and multiple sclerosis. Review of the Physician orders located under the orders tab in the EMR revealed and order dated 06/12/24 for regular diet, mechanical soft. Special Instructions: finger foods, health shake for breakfast only, provide large portions at meals. 4. Review of R171's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnoses that included dementia, schizoaffective disorder, bipolar disorder, borderline personality disorder, major depressive disorder, generalized anxiety disorder, and unspecified severe protein-calorie malnutrition. Review of the 10/30/24 Physician orders located under the orders tab in the EMR revealed Regular diet, health shakes with meals. Special instructions: large portions for breakfast with cheesy eggs, power potatoes for lunch. 5. Review of R50's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnoses that included Alzheimer's disease, schizophrenia, depression, and generalized anxiety disorder. Review of the Physician Orders dated 09/12/24 located in the EMR under the orders tab revealed Regular diet. Health Shakes with each meal TID [three times a day]. 6. Observations of the residents' meals during the survey from 11/11/24 - 11/14/24 revealed the following: No health shakes were provided to R35, R71 and R50 for breakfast, lunch, or dinner on 11/11/24, 11/12/24, and 11/13/24. Interview on 11/13/24 at 1:30PM, the DM confirmed that health shakes were not prepared for any of the residents' meals. No power potatoes were provided for R171 on 11/11/24 and 11/12/24 when potatoes were served. Interview with the Dietary Manager (DM) on 11/13/24 at 1:30 PM revealed he did not prepare or serve power potatoes all week starting 11/11/24 through 11/13/24. 7. Review of R4's EMR profile tab Face sheet revealed R4 was last admitted [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis, type 2 diabetes, iron deficiency anemia, and abnormal weight loss. Review of R4's EMR, physician orders under the orders tab revealed a diet order dated 04/22/24 for a regular diet with a Nepro shakes added to all three meals, potatoes three times each week, and large protein portions for all meals. Lunch observations on 11/11/24, 11/12/24 and 11/13/24, and breakfast observations on 11/13/24, R4 did not receive health shake. or large portions of protein for all meals. 8. Review of R26's EMR profile Face sheet revealed R26 was admitted [DATE] with diagnoses of abnormal weight loss, Vitamin D deficiency, hypertensive heat disease, anemia, and mild protein-calorie malnutrition Review of R26's EMR physician orders under the orders tab revealed a physician order dated 09/12/24 for a regular diet with a health shake added to all three meals, and with cheesy eggs and super cereal for breakfast and ice cream for lunch and supper. Lunch observations on 11/11/24, 11/12/24 , and 11/13/24, and breakfast observations on 11/13/24, revealed R26 did not receive a health shake or ice cream with any of his lunch meals, and no health shake, cheesy eggs, or super cereal for his breakfast meal. During an interview with the Administrator on 11/13/24 at 11:30 AM, she stated her expectation was for the DM to immediately begin serving special diets as ordered and to learn how to order health shakes as needed. The facility policy was requested from the DM, however, was not provided by the survey team's exit from the facility. 11599 36917

Based on observations, interviews, and record review, the facility failed to provide an alternative communication device for one resident (Resident (R) 35) of 26 sampled residents which failed to allow R35, who is non-verbal, a means to express himself. Findings include: Review of R35's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with diagnoses of cerebral palsy, generalized anxiety disorder, mood disorder, conversion disorder with seizures or convulsions, dysphagia, and multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) located in the EMR under the RAI tab, with an assessment reference date (ARD) of 09/17/24 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated R35 was not able to answer the questions. R35 was identified to be non-verbal. Review of the Care Plan located under the RAI tab in the EMR dated 09/13/24 did not identify how the resident would communicate his wants or needs. During an interview on 11/12/24 at 4:02 PM, the Administrator stated, He understands, he knows what you're saying, he can communicate. When asked if R35 had ever had a communication board or communication device, the Administrator stated, no. When asked, the Administrator stated, Well, he knows what you say. A communication board would be a good idea. During an interview on 11/14/24 at 10:11 AM, a certified nursing assistant (CNA19), who has worked with R35 since his admission to the facility, confirmed the resident does not have a communication board or device. On 11/14/24 at 02:17 PM, R35 was asked to answer a question using a thumbs up for yes or a thumbs down for no, or to shake his head up and down for yes or shake his head side to side for no. R35 was asked if he had ever had a communication board or a communication device to be able to communicate with staff and others. R35 shook his head back and forth in a no gesture. R35 was asked if a communication board or device would be helpful to him to communicate, R35 shook his head up and down in a yes gesture.

Based on observation, interviews, and record review, the facility failed to treat four of 26 sample residents (R) 14, R27, R171, and R220) with dignity and respect by failing to assist R171 with clean socks, to assist R220 to obtain clothing to wear instead of the hospital gown, and staff standing while assisting two (R27 and R14) residents to eat their meal. These failures created an undignified manor of care for the four residents. Findings include: 1. Review of R171's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R171 was admitted [DATE] with diagnoses of dementia, schizoaffective disorder, bipolar disorder, borderline personality disorder, generalized anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R171 was severely cognitively impaired. On 11/11/24 at 11:30 AM, R171 was observed wearing yellow non-skid socks and no shoes. The socks were black, with dirt, from the toes to the arch of his foot. The resident propelled himself in his wheelchair using his feet. On 11/12/24 at 09:45 AM, R171 was observed wearing yellow non-skid socks which were black from the toes to the arch of the foot all around the sock. During an interview on 11/12/24 at 1:07 PM, R171 acknowledged that his socks were dirty. When asked if he had a clean pair, R171 stated, You have to ask the nurse. The resident did not know if he had asked for a clean pair. On 11/13/24 at 8:21 AM and 11/14/24 at 10:20AM, R171 was observed wearing yellow non-skid socks that remained black all around from the toes to the arch of his foot. During an interview on 11/14/24 at 1:30 PM, the certified nursing assistant (CNA15) stated I know I gave him a pair, I don't know what he did with them. When CNA15 was asked if staff assist the resident to change soiled socks, CNA15 did not answer. During an interview with the Administrator on 11/14/24 at 10:20 AM, she stated, R171 should have a clean pair of socks. 2. During the initial screening of R220 on 11/11/24 at 10:42 AM, she stated she did not have any clothes to wear and had been wearing a hospital gown since her admission to the facility. When asked if she had notified a staff member that she needed clothes, she said I didn't know who to ask but they can see I do not have any clothes. She said she did not have family members that could bring clothes for her to the nursing facility and that it was her choice to have clothes to wear instead of a hospital gown. With the permission of R220, inside of her closet were two items, a blue pair of shorts and a black t-shirt. The storage drawers were empty. Review of R220's electronic medical record (EMR), profile tab, face sheet revealed R220 was admitted [DATE] with diagnoses acute kidney failure, generalized muscle weakness, and obesity. Review of R220's EMR admission MDS with an ARD of 09/17/24 revealed a BIMS score of 14 of 15, which indicated R220 was cognitively intake. During an interview with CNA3 and Licensed Practical Nurse (LPN)2 on 11/13/24 at 11:32 AM, both stated they had not noticed R220 needed clothing. During an interview with the Administrator on 11/13/24 at 2:36 PM, she stated that she did not know of a resident in the facility that needed clothing and that the nursing staff would let her know. She stated the facility has an orphan room where discarded clothes are kept. She said if the discarded clothes would not fit a resident, then new clothes are purchased for the resident. She said she was not notified that R220 had no clothing since her admission two months ago. During an interview on 11/14/24 at 2:55 PM, the Administrator stated her expectation was for staff to notify her of residents in need of clothing and that it was unacceptable for a resident to stay in a hospital gown unless it is the choice of the resident. 3. Review of the R27's admission MDS with an ARD of 10/04/24 under the MDS tab of the EMR revealed the resident was admitted to the facility on [DATE] with diagnoses of Non-Alzheimer's Dementia, and Macular Degeneration. The MDS indicated a BIMS score of 10 out of 15 indicating R27 was moderately cognitively impaired. Review of the R14's Significant Change MDS with an ARD of 08/26/24 under the MDS tab of the EMR revealed the resident was admitted to the facility on [DATE] and diagnoses of dysphagia and unspecified intellectual disabilities. The MDS indicated a BIMS score of three out of 15, indicating R14 was severely cognitively impaired. During an observation of meal service on 11/11/24 at 12:40PM to 12:45PM, CNA19 stood while feeding R27 his lunch meal. During an observation of meal service on 11/11/24 at 12:45 to 12:50 PM, CNA19 stood over R14 while feeding his lunch meal. During an interview on 11/11/24 at 01:15 AM, CNA19 stated that we are supposed to get a chair and sit when we assist a resident with their meal. During an interview on 11/11/24 at 01:15 AM, CNA15 stated I always stand, it's easier for me. During an interview on 11/11/24 at 01:45 AM, the Director of Nursing (DON) stated that staff should always sit and make eye contact with residents while assisting them with meals. They should never stand over them. 36917 39857

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of three errors occurred out of 30 opportunities for error due to residents not receiving their medications on time for one resident (Residents (R)11) of six residents observed for medication administration. In addition, one of six residents (R41) received a medication that did not have a physician's order. The facility medication error rate was 6.67%. This failure had the potential to affect the accurate dosing of medication administered to the residents. Findings include: 1. During medication administration observation on 11/13/24 at 8:37AM, Licensed Practical Nurse (LPN)1, administered R1 Daily-Vite with folic acid tablet (MVI) one tablet. Review of R41's Physician Orders dated November 2024 in the electronic medical record (EMR) under the Orders tab indicated there was not a physician's order for the Daily Vite with folic acid medication. 2. During medication administration observation on 11/13/24 at 9:55AM, Certified Medical Technician(CMT) 2 administered R11's Buspar 15 milligram (mg) 1 tablet that was ordered for 7:30AM. Review of R11's Physician Orders in the EMR under the Orders tab revealed, Buspirone 15 milligram (mg) one tablet twice a day. Review of R11's Medication Administration Record (MAR) dated November 2024 indicated Buspirone 15 mg one tablet was to be administered at 7:30AM and 4:00PM. Interview on 11/14/24 at 1:00PM, LPN1 was asked what the parameters of time for medication administration was. LPN1 said one hour before to one hour after was acceptable. LPN1 said it would be a medication error if the medication was given outside of this parameter. LPN1 stated regarding the multi vitamin and the folic acid, LPN1 stated that the medication should not be given if it is not ordered. Interview on 11/14/24 at 1:15PM, CMT2 was asked what the parameters of time for medication administration are. CMT2 said one hour to one hour after was acceptable. Interview on 11/14/24 at 2:15PM, the Director of Nursing(DON) was asked what the parameters of time for medication administration are. The DON said one hour to one hour after was acceptable. The DON said medication administered outside of these parameters would be a medication error. When asked if a medication should be given if there isn't a physician order, the DON said, Absolutely not.

Based on observations, and interviews, the facility failed to ensure that the food residents received was at an appetizing temperature for one of three meals on one of four survey days. The deficient practice has the potential to affect all 69 residents who receive food from dietary. Findings include: Observation of food temperatures on the steam tabled revealed the regular diet pot roast was 174 Fahrenheit (F), the scalloped potatoes were 202 degrees F and the winter vegetables were 175 degrees F. The cart left the kitchen at 12:40 PM and arrived at the first floor at 12:42 PM. Lunch was scheduled to be served at 12:00 PM. Observation on 11/13/24 at 1:10PM of the test tray temperatures on the first floor kitchenette revealed using a facility thermometer pot roast 106 F. The pot roast tasted cool. Interview with the Dietary Manager (DM) at the time, he stated that the pot roast tasted cold to him. Interview with R11 at 1:15 PM on 11/13/24, after she had finished her meal, she stated the pot roast tasted cold. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 09/24/24 Interview with the DM on 11/13/24 at 1:20 PM stated there are no food temperature logs on the unit prior to the food service nor food temperature logs in the kitchen prior to the food leaving the kitchen and being transported to each of the two units. Interview with the Registered Dietician (RD) on 11/14/24 at 10:50 AM, she indicated the expectation is that food temperatures should be taken prior to the food leaving the kitchen and prior to service and a log of such events should be maintained. The facility policy was requested of the DM; however, no policy was provided prior to the survey team exiting the facility.

Based on observation, interview, and record review, the facility failed to provide needed care in accordance with the resident's preferences for one of one resident (Resident (R)220) in the sample of 26 resident reviewed for skin care This failure had the potential to affect the physical, mental, and psychosocial health and well-being of the resident. Findings include: Review of R220's electronic medical record (EMR)Face sheet under the profile tab revealed R220 was admitted [DATE] with diagnosis acute kidney failure, generalized muscle weakness, and obesity. Review of R220's admission Minimum Data Set (MDS) in the EMR under the MDS tab with an assessment reference date (ARD) of 09/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R220 was cognitively Intact. Observation on 11/11/24 at 10:42 AM, revealed R220's feet and legs that appeared to be extremely dry with flaking skin onto the bedsheets. Interview with R220 at this time, she stated she would like to have something done for her feet and legs. She said she thought she had a prescription for some ointment, but no one ever puts it on her feet and legs. During subsequent observations of R220's feet and legs, on 11/12/24 at 11:00 AM and 11/13/24 at 2:45 PM, her feet and legs appeared to be extremely dry and scaling with dry skin flaking on the bedsheet. Review of the EMR Physician orders dated 11/13/24 indicated an order for white petrolatum gel be applied topically to bilateral feet and legs daily for 2 weeks. During an interview with Certified Nursing Assistant (CNA)3 and Licensed Practical Nurse (LPN)2 on 11/13/24 at 11:32 AM, LPN2 said R220 had been prescribed a cream to treat her dry feet and legs but said it had not been done on her current shift and did not know why the cream had not been used. CNA3 said she did not have the task on her daily assignment sheet to apply the cream to R220's legs and feet. During an interview on 11/14/24 at 2:55 PM, with the Director of Nursing (DON) and the Administrator, the DON stated her expectation of the nursing staff was to be more attentive to R220's dry scaling skin and to apply the special ointment as prescribed.

Based on observation, interview and record review, the facility failed to provide adequate supervision on a secured unit for one resident who was on 1 on 1 supervision (Resident #2). The facility also failed to lock the second floor medication room and the staff break room, leaving medications accessible to residents. These deficiencies had the potential to affect all residents who could access these areas. Additionally, the facility failed to update a resident's care plan after he/she allegedly drank hand sanitizer and was sent to the hospital after being found unconscious in his/her room (Resident #1). The sample size was 7. The census was 78, with 31 residents on the secured unit. Review of the facility's Accident and Supervision policy, undated, showed the following: -The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents; -The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents; -All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident; -Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Review of the undated Medication Storage Policy, showed: -It is the policy of the facility to ensure all medications housed on their premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security; -General guidelines: a. All drugs and biological's will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls; b. Only authorized personnel will have access to the keys to locked compartments. 1. Review of Resident #2's electronic medical record, showed diagnoses included cerebral palsy (CP, a group of disorders that affect a person's ability to move and maintain balance and posture), multiple sclerosis (MS, potentially disabling disease of the brain and spinal cord), conversion disorder (a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurological pathology) with seizures or convulsions and dysphagia (swallowing difficulties). Review of the resident's progress notes, showed the following: -On [DATE] at 10:29 P.M., as staff was getting resident ready for bed, the resident slapped the staff and began to scratch the staff, began to punch him/herself in the face and bite the side of his/her lip. The staff was finally able to calm him/her down. Staff contacted the resident's emergency contact and attempted to contact the resident's physician; -On [DATE] at 10:44 A.M., the resident became physically aggressive with the nurse practitioner (NP) and refused care. She gave an order to send the resident to the hospital for an evaluation. At 3:52 P.M., the NP noted the resident was non-cooperative, combative, aggressive, and a danger to him/herself and others. At 10:14 P.M., the resident was sent back to the facility with no new orders; -On [DATE] at 12:54 P.M., social services had contact with legal guardian to make aware of findings of resident to resident altercation; -On [DATE] at 5:56 A.M., the resident continues to go into residents' rooms and go through their things. When staff try to redirect him/her, he/she tries to fight. The residents are afraid of him/her They yell when he/she starts to come near them. Will continue to monitor. At 8:16 P.M., resident continues to go into room [ROOM NUMBER]. He/She has eaten all of his/her snacks that family has brought to him/her. He/She will go into his/her room and get into his/her drawers and sit in his/her recliner and eat his/her snacks. Staff try to redirect him/her but it does no good. Will continue to monitor; -On [DATE] at 11:56 A.M., resident bit fell ow resident twice in right forearm. Resident bit fell ow resident's skin with one bite. Staff called resident's family member and telephone number was disconnected. Call placed to resident's physician. At 2:58 P.M., resident refused to have vitals taken; -On [DATE] at 2:06 P.M., resident remained on 15 minute checks. He/She is up in wheelchair. Propels self throughout hallways. He/She wanders in other residents' rooms. At 4:14 P.M., staff emailed an immediate discharge notice to the resident's guardian and [NAME] (Ombudsman). A copy was emailed to the Director of Nurses (DON) to have available to provide to the Emergency Medical Technician (EMT) and hospital. At 5:52 P.M., the resident was transported to the hospital via ambulance. Staff gave the immediate discharge to the resident and the EMT staff and sent a copy to the hospital intake coordinator. Review of the resident's care plan, dated [DATE], showed the following: -Problem: Falls: Resident at risk for falls due to MS. Will often get out of chair and begin ambulating on knees. Placing at risk for falls due to unstable ambulation; -Approach: Increased staff supervision with intensity based on resident need; -Problem: Resident has episodes of yelling and screaming, refusing and resisting care. Agitation and angry outbursts. He/She will become angry when he/she cannot use iPad due to charger being lost. Had several chargers however will chew them causing them to be dysfunctional. Due to this, he/she will become aggressive towards staff often biting and scratching them at times. Bit another resident on [DATE]; -Approach: Send resident to emergency room (ER) for immediate discharge. Place resident on 15 minute checks. 1:1 visits as needed for support and validation. Meds as ordered and observe effectiveness. Notify MD as needed. Observe for changes in mood/cognition and behavior. Psych consult as ordered. Redirect resident as needed. Remove resident as needed. Remove resident as needed to prevent harm to self or others; -Problem: Resident exhibits wandering behaviors and is at risk or injury related to impaired safety awareness. Wanders in and out of residents' rooms. Will often eat their food which makes them upset putting him/her at risk for injury. Eats out of other residents' trays which puts him/her at risk for aspiration due to mechanical soft diet; -Approach: Anticipate needs for resident as much as possible. Approach resident in a calm manner. Calmly redirect and cue as needed. Encourage resident to participate in activities of interest as tolerated. Keep environment free of clutter and obstacles to reduce risk of injuries. Monitor any significant changes of behavior. Psych consult as ordered. Redirect resident as ordered. Remove resident as needed to prevent harm to self or others. Review of the resident's progress notes, showed the following: -On [DATE] at 7:27 P.M., resident returned from the hospital -On [DATE] at 8:41 A.M., the NP saw the resident due to aggressive behavior. The resident scratched at another resident who tried to stop him/her from eating out of the trash can. He/She refused to let the NP take his/her vital signs. Resident was combative and would not let her do assessment or vitals. Resident would be going to hospital and possibly be immediate discharge. Will send resident to hospital for further evaluation and treatment due to aggressive/violent behavior. At 1:10 P.M., a note at 7:55 A.M., the resident was involved in resident to resident altercation. Another resident asked him/her not to eat from the trash, and he/she grabbed that resident by both arms and dug his/her fingernails in causing superficial scratches to both arms and hands. The resident was on 1 on 1 monitoring. Staff notified the psychiatric NP and were awaiting hospital transport. At 3:26 P.M., a note at 10:15 A.M., staff sent the resident to the hospital due to aggressive behaviors. He/She attacked another resident and will be given an immediate discharge. At 9:58 P.M., the resident returned from the hospital with no new orders. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Severely cognitively impaired; -Wandering occurred daily. Observation on [DATE] at 6:20 A.M., showed a staff member leaving the facility. Observation of the second floor and interviews on [DATE] between 6:25 A.M. and 6:40 A.M., showed the following: -No staff visible on the floor; -One unidentified resident seated in the main dining room adjacent the kitchenette. The resident said there were two staff working overnight. One had gone home and he/she did not know where the other one had gone. He/She had not seen the staff in a little while; -A large puddle of urine in the hallway between the dining room and the nurse's station; -Several residents were up and dressed in their rooms; -There was no staff at the nurse's station at the end of the hall. Two residents sat in front of the nurse's station including Resident #2. He/She was taking snacks off a tray located on the counter on the nurse's station and eating them. The medication room was unlocked and slightly ajar. There was no staff in the medication room; -There was no staff in the television room at the end of the next hall. There was a resident at the table in the room. The staffing room was unlocked and accessible to residents; -There were residents up and dressed throughout the hall in their rooms; -At approximately 6:40 A.M., the resident in the dining room yelled, The staff is here and the Assistant Director of Nursing (ADON) could be seen walking down the hall. She was in a room, making a bed. She then walked down to the nurse's station and got Resident #2 and took him/her to his/her room. She noticed the large puddle of urine in the hallway and called for housekeeping to come clean it; -The medication room remained unlocked; -At 6:45 A.M., the ADON got on the cell phone and called to have staff from the other floor come to the second floor for assistance; -At 6:50 A.M., Certified Nurse Aide (CNA) H entered the unit from the stairwell. During observation and interview on [DATE] at 6:43 A.M., the ADON said she did not know why there was no staff on the floor. There was supposed to be two CNAs, a Certified Medication Technician (CMT) and an extra staff person assigned to Resident #2 for a one on one. She usually comes in early and the staff should have waited for her to come in before leaving the floor unsupervised. She walked around the floor several times trying to find a staff member. During an interview on [DATE] at 6:55 A.M., CNA H said he/she did not realize he/she was gone that long. He/She was doing his/her charting for the night. He/She did not realize the medication room was unlocked. Observation of the second floor unlocked and open staff break room on [DATE] from 9:10 A.M. to 9:25 A.M., showed the following; -One bottle of naproxen sodium (pain reliever), in a basket on the desk; -One bottle of aspirin, in a basket on the desk; -One bottle of allergy relief medication, in a basket on the desk; -One box of albuterol sulfate solution (used to treat or prevent the symptoms of asthma, emphysema, and other breathing conditions) on the desk; -One 8 oz bottle of hand sanitizer on the desk; -Two residents, seated outside the room watching television; -No staff in the area. Observation of the second floor medication room at 10:00 A.M., showed the following: -A refrigerator with pre-filled injectable antipsychotic medications and insulin; -An unlocked cabinet with over the counter medications such as vitamins, laxatives and cough medicine; -A box on the floor adjacent to the door, filled with expired and unused resident medications. During an interview on [DATE] at 8:45 A.M., the NP said the medication room should never be left unlocked, especially on a dementia unit. The residents should be supervised at all times. During an interview on [DATE] at 11:00 A.M., the DON said the second floor should be staffed with two CNAs, a CMT and one staff for one on one for Resident #2. Someone should have been with Resident #2 at all times. The medication room should have been locked at all times. During an interview at 11:15 A.M., the Administrator said the staff should not have left the floor unsupervised. Resident #2 should have had one on one supervision all times. She was not aware staff left the residents unsupervised until the ADON called her that morning. She expected staff to remain with the residents until they were relieved. The medication room should not have been left unlocked. Staff should not have left medication in the staffing room or should have locked it up. During an interview on [DATE] at 9:35 A.M., the Medical Director said the facility should not leave the medication room unlocked and accessible to residents. This could be dangerous if residents got access to medication. 2. Review of Resident #1's admission MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Wandering: Occurred daily; -Does wandering place the resident at risk of getting to a dangerous place: Yes; -Diagnoses included chronic kidney disease, encephalopathy (damage or disease that affects the brain), dementia with other behavioral disturbances and Alzheimer's Disease. Review of the resident's electronic physician orders, dated ,d+[DATE], showed no order for ethanol alcohol. Review of the resident's progress notes, showed the following: -On [DATE] at 2:59 A.M., the resident up attempting to walk in the hall but directed back to room by staff; -On [DATE] at 2:33 A.M., staff found sitting on the floor where other residents use the phone at 12:30 A.M., no injuries noted. At 11:47 P.M., resident very aggressive on evening shift, tried to take things off the medication cart and going behind the desk. Hard to redirect and becomes aggressive and tries to fight. Refused to go to room; -On [DATE] at 12:10 P.M., the DON interviewed staff about the resident hitting others. The resident was combative with staff with redirection. If staff gets close to direct the resident, he/she will hit them; -On [DATE] at 8:37 P.M., the staff notified the nurse the resident had fallen. Upon entering the resident's room, the resident was unconscious. The resident checked the resident's pulse which was present and called 911. The nurse sternum rubbed the resident and he/she arose to the pain. Vitals were taken and documented. The resident had a laceration to his/her right eyebrow. The nurse was able to control the bleeding before EMS arrived. The resident was taken to the hospital. Review of the resident's hospital discharge paperwork, dated [DATE], showed the following: -Presented from nursing home after he/she was found with decreased responsiveness; -Ethanol level was 28.7 (At ,d+[DATE] mg/dL, mild euphoria, decreased inhibitions, diminished attention & judgement). Review of the resident's care plan dated [DATE], showed the following: -Problem: Activities of Daily Living (ADL) Functional Status/Rehabilitation Potential. Resident needs assistance for ADLs related to dementia; -Approach: Assist as needed with ADLs. Assist as needed with toileting. Call light within reach while in room. Ensure proper body alignment when in bed or chair. Observe skin condition with daily care; -Problem: Cognitive Loss/Dementia: Resident is cognitively impaired due to dementia; -Approach: 1:1 visits as needed for sensory stimulation. Anticipate all needs for resident. Call resident by name upon each interaction. Escort resident to activities as tolerated for sensory stimulation. Observe for response. Provide total care as needed; -Problem: Falls: Resident at risk for falls related to dementia; -Approach: Encourage resident to assume a standing position slowly. Send to ER for eval and treat. Observe frequently and place in supervised area when out of bed. During an interview on [DATE] at 6:50 A.M., CNA H said the resident would wander all night long. He/She went into other residents' rooms and took their things. This would upset the other residents. The resident was very large and could be intimidating to residents and staff. He/She would take the hand sanitizer off the wall. CNA H reported it to administration once. No one told him/her the resident had alcohol in his/her system at the hospital and or it was thought he/she might have been drinking the hand sanitizer. During an interview on [DATE] at 7:15 A.M., CNA D said the resident would wander in and out of resident rooms all the time. He/She would pick things up off the desk and try to fight the staff if they tried to get it back. The resident was very hard to redirect. He/She had hit CNA D a couple of times when the CNA tried to redirect the resident. No one told CNA D the resident was potentially drinking the hand sanitizer. He/she knew they had removed the hand sanitizer from the walls but did not know why. During an interview on [DATE] at 10:30 A.M., CNA E said he/she had seen the resident going in and out of resident rooms. The resident would go behind the nurse's station and try the med room door. CNA E heard the resident drank hand sanitizer but had never seen him/her do it. During an interview on [DATE] at 2:35 P.M., the ADON said they did not know how the resident got the alcohol in his/her system. They thought he/she might have drank the hand sanitizer which was located on the walls in the hallways. They had gone around and removed them. They should have updated his/her care plan. The resident could still have access to hand sanitizer if he/she was going into resident rooms or areas where he/she was not supposed to be. During an interview on [DATE] at 8:45 A.M., the NP said the facility needed to provide closer supervision around hand sanitizer and should have added it to the resident's care plan if they suspected that was how he/she got it in his system. Staff should know how to monitor the resident and could not do that if they were not given the information. During an interview on [DATE] at 11:00 A.M., the DON said he/she did not know the resident went behind the nurse's station and tried to get in the medication room. She did not think the hand sanitizer needed to be in the care plan because they removed it from the walls. During an interview on [DATE] at 11:15 A.M., the Administrator said she should have let the MDS Coordinator know the resident had a potential problem with the hand sanitizer so it could be added to his/her care plan. The resident could still get access to it if he/she wandered into other resident rooms or areas where it might be stored and staff needed to be aware of this. During an interview on [DATE] at 9:35 A.M., the Medical Director said the facility notified him about the positive alcohol result. The staff had investigated and believed the resident might have gotten into the hand sanitizer. The staff should update the resident's care plan for added supervision to monitor him/her if they suspected the resident of drinking hand sanitizer for his/her safety. MO00217418

Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety of one confused resident (Resident #602), who eloped from the second floor (designated secured unit) early in the morning and did not return to the facility until approximately 19 hours later. The facility had assessed the resident to be at risk for elopement, and the resident had wandered away from his/her home prior to a hospitalization and subsequent admission to the facility. When the resident had increased agitation during the evening and night shift, prior to the elopement, staff did not put interventions into place to adequately monitor and address the resident's behaviors. Staff held the resident's door so he/she could not exit and administered a medication that was not prescribed in an effort to control the resident's behaviors. The facility failed to follow their elopement policy when the staff member who found the resident missing did not immediately notify the nurse or other staff to begin an expedient search. The staff also failed to notify administration or the police in a timely manner, delaying the search. Three residents at risk for elopement were included in the sample and problems were found with one. The census was 85. The administrator was notified on [DATE] at 4:15 P.M., of an immediate jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility Elopements and Wandering Residents policy, dated 2021, showed: Date Implemented: Blank; Date Reviewed/Revised: [DATE]; Policy: -This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of addressing the unique factors contributing to wandering or elopement risk; Definitions: -Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless; -Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements; 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner; 3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary; 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team; b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan; c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff; d. Adequate supervision will be provided to help prevent accidents and elopements; e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly; f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff; 5. Procedure for Locating Missing Resident: a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code); b. The designated facility staff will look for the resident; c. If the resident is not located in the building or on the grounds, administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office; d. Director of Nurses (DON) or designee shall notify the physician and family member or legal representative; e. Police will be given a description and information about the resident, include any photos. Observation on [DATE] through [DATE] showed the facility located one-half block away from a busy road with four-lanes, and an additional turn lane. Review of Resident #602's medical record, showed the following: -Hospital paperwork, dated [DATE], showed: *The resident was admitted to hospital on [DATE], after found sleeping in an alley and found to have altered mental status; *Alert and oriented one to two (person, place) depending on instances. Having memory changes chronically for one year, and more so over the last two months after moving. Most likely early-onset, quickly progressing Alzheimer's disease with concerns for visual hallucinations. With impulsiveness changes and lack of social regard. Reported hallucinations of deceased family members and behaviors of violating social norms; *Decreased awareness of safety; *Assistance required to identify errors made; *Fall risk; *Decreased cognition; *Impaired judgement; *Patient will benefit from skilled nursing facility services. Impairments in cognition and judgement, limiting judgement, limiting capacity for successful independent mobility; -admitted to facility on [DATE]; -Diagnoses included acute necrotizing hemorrhagic [CONDITION(S)] (a rare central nervous system (CNS) complication secondary to influenza or other [CONDITION(S)] infections which is characterized by altered mental status and seizures), type 2 diabetes, high blood pressure and Alzheimer's Disease; -No MDS assessment information regarding cognitive abilities. Review of the resident's progress notes, showed the following: -On [DATE] at 10:57 P.M., the resident was confused and disoriented. He/she was experiencing signs of short-term memory loss; -On [DATE] at 2:39 P.M., the resident asked several times how he/she could get out but made no attempts to elope and is easily redirected. Admission elopement evaluation, dated [DATE], showed: Evaluation: Complete for residents who ambulate independently, with or without an assistive device: -Does the resident have a history of, or an attempted elopement, while at home: Yes; -Does the resident have history of, or attempted leaving the facility, without informing staff: No; -Has the resident verbally expressed the desire to go home, packed belongings to go home, or stayed near the exit door: No; -Does the resident wander: Yes; -Is the wandering behavior a pattern, goal directed (specific destination in mind, going home etc): No; -Does the resident wander aimlessly or non-goal directed (confused, moves without purpose, may enter others' rooms and explore others' belongings): Yes; -Is the resident's wandering behavior likely to affect the safety of well-being of self/others: Yes; -Is the resident's wandering behavior likely to affect the privacy of others?: Yes; -Has the resident been recently admitted or readmitted (within past 30 days) and is not accepting the situation: Yes; -Clinical suggestions: -Apply identification bracelet: blank/unchecked; -Apply personal safety alarm devices: blank/unchecked; -Monitor location frequently: blank/unchecked; -Utilize exit alarm: blank/unchecked; -Utilize check in/out log: blank/unchecked; -Document specific behaviors on the behavior log: blank/unchecked; -Encourage participation in recreational activities such as exercise, music therapy or group activities: blank/unchecked; -Personalize room with familiar objects and/or photographs: blank/unchecked; -Review current medication regimen: blank/unchecked; -Utilize visual barriers: stop signs, ribbons, tapes: blank/unchecked; -Notify staff of elopement risk: blank/unchecked; -Notify staff of wandering risk: blank/unchecked; -Scoring: At risk, a score above 1; -Elopement risk score total is 6.0, or at risk; -Assessment signed as effective on [DATE]. Review of the resident's social service history and initial assessment dated [DATE], showed the following: -Resident left from home and was missing for three days prior to placement in facility; -Behavior Factors: Exit seeking, Wandering; -Discharge planning: Potential barriers to discharge? Yes: Exit seeking behavior. History of missing person. Further review of the resident's progress notes, showed a late entry on [DATE] at 10:57 P.M., the resident had severe cognitive impairment. The resident was unable to complete the interview for mental status. The mood interview could not be conducted. The resident rarely/never understood. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident is at risk for elopement (date initiated [DATE]); -Goal: The resident will remain within eyesight of staff; -Interventions: Clearly identity the resident's room and bathroom, identify if there is a certain time of day wandering/elopement attempts occur, engage the resident in meaningful activities and schedule times for walks and activities; -Focus: Impaired coping; -Goal: Resident will be free of and/or anxiety; -Interventions: Encourage resident to verbalize feelings regarding fear and/or anxiety. Encourage times of rest and relaxation between care activities. Evaluate the cause of fear or anxiety. Review of the facility self report investigation summary, dated [DATE], completed by the DON, showed on [DATE] at 4:30 A.M., the alarm sounded. Per the staff on duty, a head count was initiated to locate residents. Resident #602 was not found. Staff searched the building for the resident and called the DON when he/she was not found. The DON came to the facility and searched the outside area. Staff called 911 after they were unable to find the resident. Review of the Weather Underground website, showed the local temperature was 36 degrees Fahrenheit (F) on [DATE] at 4:51 A.M. Observation on [DATE] at 6:48 A.M., showed an exit door approximately 75 feet from the resident's room. A sign on the door read, Push until alarm sounds, door can be opened in 15 seconds. Review of a written statement, dated [DATE], by Certified Nurse's Aide (CNA) E, showed upon his/her arrival to work at 11:00 P.M. on [DATE], the resident was up walking around upstairs, so he/she tried to talk him/her into going back to his/her room but he/she did not want to go. He/she kept talking and walking with the resident around the circle of the nurse's station for about an hour. By 1:00 A.M., the resident went and lay down. CNA E told the resident's CNA, the resident was in his/her room, hopefully tired and lying down, and he/she went back to his/her own residents. During interview on [DATE] at 6:10 A.M. and on [DATE] at 6:40 A.M., CNA E said he/she arrived at work around 11:00 P.M. on [DATE]. The resident was already agitated. He/she was going into other resident rooms and bothering them. The resident was not on the CNA's hall, but he/she normally worked the assignment with the resident, so he/she attempted to intervene by walking with him/her for about an hour, but he/she would not respond to him/her. The CNA finally had to turn him/her over to CNA D who was assigned to the resident. The resident had been expressing wanting to leave the facility since his/her admission. The CNA did not know about any specific interventions put in place for the resident, but he/she knew from working with residents like this, when residents are agitated and trying to leave, staff should make frequent checks on them. Based on how agitated the resident was, he/she would have checked on him/her every 15 minutes. He/she did not hear the alarm go off. He/she was assigned to the other side of the second floor, and he/she could not hear the alarm from that side of the building. Review of an undated, written statement by CNA D, provided by the facility, showed he/she worked with the resident the prior night and he/she was agitated and wanted to go home. The CNA asked the nurse to give him/her a sleep medication because he/she was walking around. The CNA convinced him/her to go to bed in his/her room. He/she closed the door with the resident in there. At around 4:00 A.M., the CNA could not find him/her in his/her room and heard the alarm sound. They looked everywhere but did not find him/her. During interviews on [DATE] at 6:20 A.M. and at 1:40 P.M. and on [DATE] at 6:45 A.M., CNA D said he/she worked a double shift that evening. The resident received a visit from his/her family earlier in the evening. The family went to leave and the resident said, I am going with you. The family told him/her no and he/she got agitated. The family told him/her about a new grandchild, and he/she wanted to see the grandchild. He/she started to disturb the other residents by walking into their rooms. The CNA tried to get him/her to calm down, but he/she was really agitated. The CNA asked the nurse for some medication to help the resident sleep, but was told he/she already had his/her medication and would eventually become calm. The CNA kept trying to talk the resident down. He/she walked him/her to his/her room, assisted him/her into a gown and into bed. Then the CNA closed the door and held the door handle. The resident got up and tried the door handle several times and then gave up. After a short period of time, at approximately 2:30 A.M., the CNA opened the door and looked in at the resident and saw him/her in bed. At 4:00 A.M., he/she went to check on the resident and he/she was not in his/her room. He/she knew the resident liked to go into another resident's room on the other side of the floor so the CNA went there to look for him/her first. When the resident was not there, he/she started to search the rooms on the second floor. When he/she came back around the corner of the hall where the resident's room was, he/she heard an alarm on the locked exit door adjacent to the elevators. The alarm was not very loud and he/she could not hear it until he/she was almost to the door. The lights on the exit door were blinking. The CNA attempted to push the door, but it was locked. He/she thought the door could not be opened without a code being pushed into the keypad. He/she did not realize there was a sign on the door indicating the door could be opened if held for 15 seconds. He/she had already searched the rooms on the second floor, so he/she decided to take the elevator down to look for the resident on the first floor. The CNA did not see the resident on the first floor, so then he/she went to look for him/her in the basement. The CNA did not tell anyone the resident was missing at this point because he/she thought he/she would find the resident. When he/she did not find the resident in the basement, he/she went to the first floor and told the nurse. The nurse told the CNA the resident must still be there, and they just needed to search for him/her. The CNA assured the nurse the resident was not in the building, but the nurse said they needed to search the whole building. The nurse told all of the staff to search the building. Once they searched the building and realized the resident was gone, they called the police. Review of an undated written statement by Certified Medication Technician (CMT) F, showed the last time he/she saw the resident was at 12:00 A.M., walking around saying he/she needed to get out so he/she could get to work on time at 5:00 A.M. He/she walked him/her to his/her room and asked him/her to please stay and get some rest. Around 4:15 A.M., the alarm on the door sounded and the resident was nowhere to be found. There was a shirt on a outdoor mailbox and one of his/her cups at the dead end behind the building. He/she searched for about two hours with no luck. During interviews on [DATE] at 7:22 A.M. and on [DATE] at 6:30 A.M., CMT F said on [DATE] around 5:00 P.M., the resident gathered all of his/her things and said he/she needed to be at work the next morning. At 8:00 P.M., his/her family visited and told him/her about a new grandchild. When the family left, he/she wanted to leave with them. The CMT tried to distract the resident by offering to let him/her talk to the social worker and gave him/her some snacks. The CMT let the nurse know the resident was talking about leaving. The nurse told the CMT to give the resident 5 milligrams of [MEDICATION(S)]. The CMT administered the medication around 9:00 P.M. and sat with the resident for around half an hour until he/she calmed down and then left him/her in his/her room. He/she checked on the resident around midnight and did not see him/her again. Around 4:30 A.M., the CMT was in a room across from the nurse's station and heard a door alarm go off and ran to check on it. He/she did not know which door alarm was sounding and it took a few minutes to find the door. When he/she got to the exit door adjacent to the elevators, he/she saw a chip bag on the floor in front of the door. The door was locked, and he/she entered the alarm and searched the stairwell but did not see anyone. After CNA D said the resident was missing, they all searched the building. After they realized he/she was not in the building, the CMT drove around and looked for the resident. The CMT found a resident's gown he/she assumed belonged to the resident not even a mile from the facility. The resident had been at the facility about two weeks. He/she had been exit seeking since his/her admission. Review of Nurse C's written statement, dated [DATE], showed at approximately 5:00 A.M., CNA D came down to the floor to notify him/her, he/she could not find the resident. The nurse informed him/her and the other staff to keep looking from room to room, and he/she ran to the basement and went through all the rooms. The staff were unable to locate the resident at the time. The nurse called the DON and she stated she would come in and look. The nurse got in his/her car and drove towards the highway to try and locate the resident. She did not find the resident, but the DON found evidence the resident was in or had been in the area. The police arrived and spoke with the DON and the nurse. During an interview on [DATE] at 7:45 A.M., Nurse D said the resident was new to the nurse. He/she just got to know him/her the night before. The resident had some forgetfulness and dementia. He/she received a call that night about a new grandchild and then a family member came to visit. After the visit, the resident was ready to go with the family. The CMT was going to give the resident his/her medication early and get him/her some snacks. Staff were able to get the resident to lie down. CNA D did say the resident got back up and asked for some medication. The nurse told the CNA, the resident had already received his/her medication, so they could not give him/her any more. The nurse did not know the resident was going into other resident rooms. The nurse thought the resident would calm down after the snacks and if they dimmed the lights. The nurse did not remember anyone telling him/her the resident continued to be agitated and was disturbing the other residents by going in their rooms. As soon as CNA D let him/her know the resident was missing, he/she told the staff to start searching room to room. He/she searched the basement. When they did not find the resident in the building, the nurse called the DON. He/she did not remember the exact time. The nurse began to search for the resident in the car. The nurse went one way, and the CMT went the other way. They found one of the facility water cups she believed belonged to the resident and knew the resident left the building. Review of a typed statement, dated [DATE] by the DON, showed the resident left of his/her own accord; he/she is his/own responsible party. The door alarms sounded around 4:30 A.M., and staff responded to check doors and do a head count of residents. When the resident was not located, staff searched all floors of the building including rooms, bathrooms, closets. The nurse on duty called the DON at 5:27 A.M. and she came to the facility to help search the surrounding neighborhood. The DON found a water pitcher on the next street over and returned to the facility to call 911 and notify the police. During an interview on [DATE] at 12:05 P.M., the DON said she did not know if there were any interventions put in place for the resident's wandering prior to [DATE]. She would have expected staff to walk and talk with him/her, entertain him/her, reach out to the physician if these interventions were not working and check on him/her more often. If the resident was agitated and exit seeking, the staff should check on the resident every ,d+[DATE] minutes tops. She did not know CNA D held the resident's door shut, so he/she could not get out. This was not acceptable. When the CMT heard the alarm, they should have immediately done a head count. The CNA should have notified the nurse as soon as he/she noticed the resident was missing so a search could have begun immediately. The DON was not called until 5:27 A.M. During an interview on [DATE] at 11:00 A.M., Detective G said the resident was found around 11:00 P.M. on [DATE], approximately 16 miles away from the facility. He/she was very confused and tried to get into a house where he/she thought he/she lived and was arguing with the homeowner. The resident was wearing a pair of jeans and a shirt but no jacket, which was concerning because the outside temperature was in the 30's that morning when he/she left the facility. The detective said the facility reported the alarm went off at 5:00 A.M., and the police did not receive a call until 6:16 A.M. During an interview on [DATE] at 11:30 A.M., the nurse practitioner said staff did not notify him/her the of the resident's behaviors the night the resident was agitated. Staff could have called him/her or the psychiatric nurse practitioner for an as needed medication. The nurse practitioner would have expected staff to make frequent checks on the resident if he/she was agitated and exit seeking that night. During interviews on [DATE] at 8:35 A.M. and at 12:00 P.M., the administrator said the exterior exit door (from the stairwell), had an alarm which only sounded for 30 seconds. She did not know staff could not hear the door alarm on the second floor from the other side of the floor. There was a lack of communication the night the resident left the building. The CNA should have alerted the nurse as soon as he/she noticed the resident missing so all staff could be alerted with an overhead page. Everyone in the building should have been looking for the resident. Note: At the time of the investigation/abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. Note: At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 053 MO 072 MO 082

Based on observation, interview and record review, the facility failed to follow their policy by failing to provide adequate supervision to ensure the safety of one resident (Resident #21) who had been admitted on the second floor (the designated secured unit) from a hospital on 4/21/21, after a suicide attempt and failed to put interventions in place when the resident continued to be elopement seeking. The facility failed to implement interventions to monitor the elevators, provide education or inservices to staff and residents, independently using the elevator, regarding elopement. The facility failed to educate all staff on residents at risk for elopement. In addition, the facility failed to provide safety for the residents by propping open one ground floor exit door, a door to a kitchen prep area and a door to a room with shaving kit supplies without staff supervision. The census was 94. The administrator was notified on 12/6/21 at 2:30 P.M., of an immediate jeopardy (IJ) which began on 4/21/21. The IJ was removed on 12/7/21 as confirmed by surveyor onsite verification. Review of the facility Elopements and Wandering Residents policy, dated 2021, showed: Date Implemented: Blank; Date Reviewed/Revised: Blank; Date Reviewed/Revised By: Blank; Policy: -This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of addressing the unique factors contributing to wandering or elopement risk; Definitions: -Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless; -Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements; 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner; 3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team; b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan; c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff; d. Adequate supervision will be provided to help prevent accidents and elopements; e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly; f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. 5. Procedure for Locating Missing Resident: a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code); b. The designated facility staff will look for the resident; c. If the resident is not located in the building or on the grounds, administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office; d. Director of Nurses (DON) or designee shall notify the physician and family member or legal representative; e. Police will be given a description and information about the resident, include any photos; f. All parties will be notified of the outcome once the resident is located; g. Appropriate reporting requirements to the State Survey agency shall be conducted; 6. Procedure Post-Elopement: a. A nurse will perform a physical assessment, document, and report findings to physician; b. Any new physician orders will be implemented and communicated to the family/authorized representative; c. A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults; d. The resident and family/authorized representative will be included in the plan of care; e. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior; f. When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternate placement in an appropriate facility; g. Documentation in the medical record will include: findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable. 1. Review of Resident #21's admission elopement evaluation, dated 4/20/21, showed: Evaluation: Complete for residents who ambulate independently, with or without an assistive device: -Does the resident have a history of, or an attempted elopement, while at home: Yes; -Does the resident have history of, or attempted leaving the facility, without informing staff: No; -Has the resident verbally expressed the desire to go home, packed belongings to go home, or stayed near the exit door: No; -Does the resident wander: Yes; -Is the wandering behavior a pattern, goal directed (specific destination in mind, going home etc): Yes; -Does the resident wander aimlessly or non-goal directed (confused, moves without purpose, may enter others' rooms and explore others' belongings): Yes; -Is the resident's wandering behavior likely to affect the safety of well-being of self/others: No; -Has the resident been recently admitted or readmitted (within past 30 days) and is not accepting the situation: Yes; -Clinical suggestions: -Apply identification bracelet: unchecked/blank; -Apply personal safety alarm devices: unchecked/blank; -Monitor location frequently: blank/unchecked; -Utilize exit alarm: blank/unchecked; -Utilize check in/out log: blank/unchecked; -Document specific behaviors on the behavior log: blank/unchecked; -Encourage participation in recreational activities such as exercise, music therapy or group activities: blank/unchecked; -Personalize room with familiar objects and/or photographs: blank/unchecked; -Review current medication regimen: blank/unchecked; -Utilize visual barriers: stop signs, ribbons, tapes: blank/unchecked; -Notify staff of elopement risk: blank/unchecked; -Notify staff of wandering risk: blank/unchecked; -Scoring: At risk a score above 1; -Elopement risk score total is 2.0 or at risk; -Assessment signed as completed on 4/22/21. Review of the resident's closed medical record, showed: -admitted on [DATE]; -discharged to the hospital on 4/22/21; -Diagnoses of kidney disease, stroke, suicide attempt and ideation, [CONDITION(S)] and anxiety. Review of the resident's care plan, dated 4/22/21, showed: -Focus: The resident is at risk for elopement; -Goal: The resident will not attempt to elope; -Interventions: Clearly identity the resident's room and bathroom, engage the resident in meaningful activities and schedule times for walks and activities. Review of the facility self report investigation summary, dated 4/22/21, completed by the DON, showed on 4/22/21 at 6:10 P.M., the DON was contacted by the second floor charge nurse that the resident was unable to be located. The DON responded to the facility to assist in the search. The resident was last observed on the second floor approximately 5:25 P.M. At approximately 6:27 P.M., the DON was notified by the nurse the resident had been located at a local pharmacy. The police responded to the pharmacy and returned the resident to the facility. The resident remained on 15 minute checks and was sent out to the hospital for evaluation. Review of the progress notes, dated 4/22/21 at 10:02 P.M., showed the resident continued to attempt to elope, he/she was placed on one to one with an aide. The resident refused care and became aggressive with staff. The nurse practitioner was notified and a new order was given to send the resident to the hospital for evaluation and treatment. Responsible party was notified. During an interview on 12/2/21 at 9:12 A.M., CNA FF said he/she had passed dinner trays the evening of 4/22/21, and the resident had not been in his/her room. He/she looked for the resident and located him/her in the stairwell. He/she did not recall the stairwell door alarm sounding (stairwell doors are secured with a delayed egress system. The door will not open unless there is constant pressure to the push bar for 15 seconds and then if opened, an alarm will sound). He/she was able to coax the resident back onto the secured unit. CNA FF thought he/she informed the nurse of the resident's attempt. (The nurse did not respond to attempts to interview.) No additional monitoring was provided after the attempted elopement. The resident ate his/her dinner tray. Approximately an hour later, when staff collected dinner trays, the resident could not be located. The staff on the second and first floor conducted a building search. The resident could not be located in the immediate area outside the building. Staff noted flashing lights at the local pharmacy up the road and the DON along with a few other staff located the resident there. During an interview on 12/2/21 at 8:00 A.M., the DON said the pharmacy where the resident was located is approximately 0.6 miles away down the busy road. While staff were looking for the resident, they noted flashing lights at the pharmacy. Some of the staff, along with the DON, drove to the pharmacy. The police were onsite. The resident only allowed the police to take him/her back to the facility. The DON remained at the facility with the resident and conducted frequent checks. The DON had not been notified the resident had a previous elopement attempt earlier that day. The staff should have documented the attempt and contacted her at the time of the earlier attempt and started immediate one to one observations. The nurse should have contacted the primary physician for orders. If the facility did not have enough staff to conduct one to one observations, then 15 minute checks would be conducted. During an interview on 12/2/21 at 10:08 A.M., the administrator said she viewed the facility video surveillance following the resident's elopement. The video showed the resident entered the second floor elevator with another resident (Resident #61) and left the second floor. The resident then exited the elevator on the first floor, went out to the courtyard, re-entered the facility on the first floor and exited through a first floor stairwell exit and left the building. The stairwells had an audible alarm (a stop sign shaped alarm that requires a key to turn on/off), however the alarm sounds for 30 seconds and then ceases alarming. No staff on the first floor reported hearing the alarm sounding. She was not made aware the resident was found in the stairwell that day, and she was not aware CNA FF did not hear an alarm sound on the door. Had she known, she would have instructed staff to continuously monitor the stairwell door and contact the maintenance director to come out and assess the stairwell door. She would have had staff monitor the resident one on one as well. During an interview on 12/3/21 at 11:37 A.M., the resident's responsible party (RP) said the resident was in the hospital for a suicide attempt and ideations. Prior to the hospitalization , the resident had resided at a different facility and eloped from that facility, was hospitalized and then discharged home. The RP spoke with the facility management prior to the resident's admission and discussed the resident's prior history of elopement. The nurse had called and informed him/her the resident was located in the stairwell earlier in the evening. The RP was called later and notified the resident had continued to attempt to elope and become aggressive with staff. The facility sent the resident to the hospital for evaluation and treatment. The facility called the RP and notified him/her of the successful elopement. The resident was not readmitted to the facility and the RP selected a more secure facility. During observation and interview on 12/2/21 at 10:41 A.M., the administrator and maintenance director set off the exterior door, identified as the door from which the resident left the building. The door alarm, labeled #5, sounded for 30 seconds and stopped alarming. Surveyors in the conference room inside the building and approximately 30 feet from the exterior door could not hear the alarm sounding. Observation on 12/2/21 at 12:28 P.M., of the area of the second floor nurses station, showed no documentation of residents who were at risk to elope from the secured unit. During an interview on 12/6/21 at 8:35 A.M., housekeeper N said he/she worked on the second floor for a few months. He/she was told at the time of orientation that the second floor was the secured unit and the unit had four residents who were exit seeking. He/she could not identify any of the four residents except by room number, since he/she cleaned the rooms. Housekeeper N said several of the residents who smoke use the elevator independently from the second floor to the first floor. He/she had not seen a list of the residents who wander. During an interview on 12/6/21 at 8:40 A.M., Licensed Practical Nurse (LPN) S said the second floor is a secured unit. There are four residents who are exit seeking on the second floor. LPN S was unsure who all four residents were. Staff attempted to monitor residents who use the elevator, but there is not enough staff. There is no list available for staff to use to identify residents who wander. Several of the second floor residents who smoke are allowed to use the elevator independently and those residents should not allow any other residents on the elevator with them. He/she had not received training on elopements in over nine months. Review of Resident #61's medical record, showed: -admitted on [DATE]; -Diagnoses of [CONDITION(S)] (mental disorder that affects the ability to think clearly), restlessness and agitation; -Ambulates independently; -Able to make needs and wants known. During an interview on 12/6/21 at 9:35 A.M., Resident #61 said he/she was on the elevator when Resident #21 quickly ran onto the elevator with him/her. Resident #61 told the other resident to get off the elevator, but Resident #21 did not exit the elevator. No staff were present for assistance. Resident #61 had been allowed to use the elevator independently to access the first floor for smoking in the court yard. The elevator door opened on the first floor and both Resident #21 and #61 exited and entered into the courtyard. He/she saw Resident #21 re-enter the building into a different doorway. After the incident, Resident #61 was moved from the secured unit onto the first floor. During an interview on 12/7/21 at 10:42 A.M., the resident's physician/Medical Director said when the resident attempted to elope earlier in the evening, staff should have conducted one to ones until he was contacted. The usual order would have been to contact the psychiatric physician. If staff had monitored the resident after the earlier attempt, the resident might not have been able to successfully elope later in the evening. The resident was sent out later in the evening on 4/22/21 related to increasing behaviors and elopement attempts and did not return. While onsite from 11/29/21 through 12/6/21, the surveyor requested evidence of elopement staff inservicing, such as sign in sheets. None was provided. During an interview on 12/7/21 at 1:04 P.M., the administrator and DON said staff had been inserviced in the last few months regarding elopements. They did not know where the inservice forms or signature pages were located and were unsure if all of the facility staff had been inserviced on elopements. 2. Review of Resident #16's quarterly MDS, a federally required assessment instrument completed by facility staff, dated 10/30/21, showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, Alzheimer's disease, dementia, anxiety and depression; -Independent with bed mobility, transfers, dressing, eating and toileting; -Required supervision with personal hygiene; -No physical behavioral symptoms directed toward others; -No wandering behavior; -Does the wandering place the resident at significant risk of getting to a potentially dangerous place?: Blank; -Does wandering significantly intrude on the privacy or activities of others?: Blank; -How does resident's current behavior status, care rejection, or wandering compare to prior assessment: Blank. Review of the facility's list of residents at risk for elopement, completed by the administrator and received on 12/2/21, showed the resident was at risk for elopement. Review of the resident's progress notes, dated 9/20/21 at 7:10 P.M., showed resident is exit seeking. He/she had packed all of his/her things and stated, I am going home to help my mom. This nurse along with CNAs, have redirected the resident several times. Review of the resident's elopement evaluation, dated 7/23/21 and 10/23/21, showed: -Does the resident have a history of an attempted elopement while at home: No; -Does the resident have a history of or attempted leaving the facility without informing staff: No; -Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: No; -Does the resident wander: No; -Is the wandering behavior a pattern, goal-directed: No; -Does the resident wander aimlessly or non-goal-directed: No; -Is the resident's wandering behavior likely to affect the safety or well-being of self/others: No; -Is the resident's wandering behavior likely to affect the privacy of others: No; -Has the resident been recently admitted or readmitted and is not accepting the situation: No. Review of the resident's care plan, dated 11/15/21, showed: -Focus: Risk for wandering/elopement identified; -Goals: Resident will not elope; -Interventions: Clearly identify resident's room and bathroom; -Engage resident in purposeful activity; -Identify if there is a certain time of day wandering/elopement attempts occur; -Implement scheduled hydration if not contraindicated; -Schedule time for regular walks/appropriate activity. Observation on 12/6/21 at 3:30 P.M., showed the resident walking around the second floor and in the dining room near the elevators. There were no staff present. 3. Review of the facility's list of residents at risk for elopement, completed by the administrator and received on 12/2/21, showed the Resident #17 was at risk for elopement. Review of the resident's elopement evaluation, dated 11/8/21, showed: -Does the resident have a history of an attempted elopement while at home: No; -Does the resident have a history of or attempted leaving the facility without informing staff: No; -Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: No; -Does the resident wander: Yes; -Is the wandering behavior a pattern, goal-directed: No; -Does the resident wander aimlessly or non-goal-directed: No; -Is the resident's wandering behavior likely to affect the safety or well-being of self/others: No; -Is the resident's wandering behavior likely to affect the privacy of others: No; -Has the resident been recently admitted or readmitted and is not accepting the situation: No. Review of the resident's progress notes, dated 11/10/21 at 7:23 A.M., showed the resident pacing in the hallway. Staff redirected the resident back to the room. Resident was arguing with the nurse asking to call a friend in the middle of the night. Staff reminded the resident he/she is on quarantine. The resident would not go back to the room. Review of the resident's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, diabetes, arthritis, dementia and malnutrition; -Independent with bed mobility, transfers, dressing, eating and toileting; -No physical behavioral symptoms directed toward others; -Verbal behavioral symptoms directed toward others: Behavior of this type occurred one to three days; -No wandering behavior; -Does the wandering place the resident at significant risk of getting to a potentially dangerous place?: Blank; -Does wandering significantly intrude on the privacy or activities of others?: Blank. Further review of the resident's progress notes, dated 11/18/21 at 1:52 P.M., showed the resident is stable. He/she seems very confused and walks around in hallways. Review of the resident's care plan, dated 12/2/21, showed no documentation that included identification of the resident's wandering risk and interventions to prevent wandering/elopement. During an interview on 12/6/21 at 11:35 A.M., Nurse S said the resident had behaviors that included wandering since he/she was admitted to the facility last month. He/she can be redirected, but only if staff have a rapport with the resident or if he/she received orange juice. Nurse S said there were no conversations with staff about the resident's current behaviors in the facility. Observation and interview on 12/6/21 at 3:30 P.M., showed the resident was outside the elevator in the dining room on the second floor. The resident said he/she looked for his/her clothes and blamed a resident who walked by. The resident said he/she did not want to be at the facility and staff were attempting to kill him/her. There were no staff present. 4. Review of the second floor 42 residents' most recently completed MDSs, on 12/7/21, showed Residents #33, #36, #50 and #59 had been identified as residents that wander daily, but were not identified on the facility list as at risk to leave the facility unsupervised. Review of Resident #33's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -No speech - absence of spoken words; -Adequate hearing and vision; -Rarely/never understood; -Sometimes understands others-responds adequately to simple, direct communication only; -Physical behavioral symptoms directed toward others: Behavior of this type occurred one to three days; -Rejection of care: Behavior of this type occurred four to six days, but less than daily; -Wandering - Presence and Frequency: Behavior of this type occurred daily; -Does the wandering place the resident at significant risk of getting to a potentially dangerous place?: Blank; -Does wandering significantly intrude on the privacy or activities of others?: Blank; -Independent with bed mobility and transfers; -Required limited assistance with guided maneuvering of limbs or other non-weight bearing assistance for walking in room; -Walk in corridor: Activity did not occur; -Independent for locomotion on the unit; -Required limited assistance of one person required for locomotion off the unit; -Mobility Devices: Wheelchair; -Diagnoses of [CONDITION(S)] (CP, a disorder caused by brain damage occurring at or before birth and marked by muscular impairment), [CONDITION(S)] (MS, a chronic progressive nervous system disorder). Review of the resident's care plan, in use during the survey, showed; -Focus Areas included: -Potential to be physically aggressive, communication problem, impaired cognitive function; -Wandering was not identified as a focus area; -Interventions include: -Monitor/document/report any signs or symptoms posing danger to self or others; -When the resident becomes agitated, intervene before agitation escalates; -Anticipate and meet needs; -Monitor/document frustration level; -Keep the resident's routine consistent and try to provide consistent care givers. Review of Resident #36's significant change in status MDS, dated [DATE], showed: -admitted [DATE]; -Adequate hearing and vision; -Unclear speech - slurred or mumbled words; -Makes self understood: Sometimes understands - responds adequately to simple, direct communication only; -Sometimes understands others-responds adequately to simple, direct communication only; -Daily wandering; -Does the wandering place the resident at significant risk of getting to a potentially dangerous place?: Yes; -Does wandering significantly intrude on the privacy or activities of others?: Yes; -Independent with bed mobility; -Required supervision - oversight, encouragement or cueing for transfers; -Walk in room/corridor did not occur; -Required extensive assistance of one person for locomotion on/off the unit; -Mobility Devices: Wheelchair; -Diagnoses of [CONDITION(S)] (low red blood cell count), arthritis, [CONDITION(S)], Alzheimer's disease, stroke and dementia. Review of the resident's care plan, showed: -Focus Areas included: -Communication problem, impaired cognitive function/dementia or impaired thought processes, safety and wanders aimlessly; -Interventions included: -Anticipate and meet needs; -Cue, reorient and supervise as needed; -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television; -Identify pattern of wandering. Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise?; -Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Review of Resident #50's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Unclear speech - slurred or mumbled words; -Adequate hearing and vision; -Makes self understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Sometimes understands - responds adequately to simple, direct communication only; -Wandering - Presence and Frequency: Behavior of this type occurred daily; -Does the wandering place the resident at significant risk of getting to a potentially dangerous place? Blank; -Does wandering significantly intrude on the privacy or activities of others?: Blank; -Supervision - oversight, encouragement or cueing required for bed mobility; -Extensive assistance of one person required for transfers; -Walk in room/corridor did not occur; -Independent for locomotion on the unit; -Total dependence of one person required for locomotion off the unit; -Mobility Devices: Wheelchair; -Diagnoses of Alzheimer's disease and dementia. Review of the resident's care plan, located in the electronic medical record (EMR) and in use during the survey, showed: -Focus Areas Included: -Impaired cognition, activity of daily living deficit, wanders the unit and can be verbally aggressive; -Interventions include: -Ask yes/no questions in order to determine the resident's needs; -Cue reorient and supervise as needed; -Total assistance of one staff for dressing, personal hygiene and toileting; -Assistance of one staff required for transfers; -Distract resident from wandering by offering pleasant diversions, activities, food or television; -Provide structured activities: Toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Review of Resident #59's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Adequate hearing; -Impaired vision - sees large print, but not regular print in newspaper/books; -Makes self understood: Sometimes understands-responds adequately to simple, direct communication only; -Usually understands others, misses some part/intent of message but comprehends most of conversation; -Physical behavioral symptoms directed toward others: Behavior of this type occurred one to three days; -Verbal behavioral symptoms directed toward others: Behavior of this type occurred one to three days; -Other behavioral symptoms not directed toward others: Behavior of this type occurred one to three days; -Rejection of care: Behavior of this type occurred one to three days; -Daily wandering; -Does the wandering place the resident at significant risk of getting to a potentially dangerous place?: Blank; -Does wandering significantly intrude on the privacy or activities of others?: Blank; -Independent with bed mobility, transfers, walking in room/corridor and locomotion on the unit; -Required limited assistance of one person for locomotion off the unit; -Diagnoses of high blood pressure, Alzheimer's disease and dementia. Review of the resident's care plan, in use during the survey, showed: -Focus Areas included: -Risk of self care deficit, impaired cognition and behavior management; -Interventions included: -Evaluate functional abilities; -Evaluate resident's ability to perform activities of daily living (ADLs); -Cue, reorient and supervise as needed; -Ensure the safety of the resident and others; -Evaluate elopement risk; -Utilize diversion techniques as needed. During an interview on 12/7/21 at 12:40 P.M., the MDS Coordinator said she did not add Residents #33, #36, #50 and #59 to the elopement list because those residents wander, but do not attempt to elope. She acknowledged it is possible one of the independent residents who use the elevator would not know these were confused residents, and allow them on the elevator with them. It is also possible one of these residents might be wandering in the area of the elevators and get on the elevator after an independent resident or a staff member exited but before the door could close. She will add those four residents to the list. During an interview on 12/7/21 at 10:50 A.M. the administrator said the four residents identified to wander, Residents #33, #36, #50 and #59 should be on the facility elopement risk list since they have been identified to wander. 5. During an interview on 12/6/21 at 6:34 A.M., Receptionist KY said he/she worked at the facility for nine years. He/she could not recall the last time the facility held an inservice on elopement and wandering. The second floor is the secured unit where residents at risk to elope or wander reside. The second floor has alarmed doors. The elevator has a thick piece of plastic covering the control panel. You have to use a thin pen to push the floor buttons for the elevator. He/she did not know the four residents the facility identified as an elopement risk, but he/she felt since he/she spends the majority of his/her time at a desk in front of the lobby exit, it would be a good idea to have a list of those residents. 6. During an interview on 12/6/21 at 7:13 A.M., Dietary aide EE did not remember when the last time he/she received in-service on elopement and wandering. Dietary Aide W said he/she received in-service sometime this year and it was mandatory. Dietary Aide EE and Dietary Aide W were aware the second floor was designated as the secured floor. There is plexiglass in front of the elevator

Based on observation, interview and record review, the facility failed to ensure a timely nutritional assessment or interventions by the Registered Dietician (RD) for residents who had a significant weight loss (Residents #40 and #41). The facility also failed to monitor and implement resident specific interventions including health shakes and fortified foods (cheesy eggs, super cereal, power potatoes and power pudding) along with larger portions sizes when ordered. The facility identified 64 residents with one or more fortified foods and/or larger portion sizes. Of those 64 residents, five were sampled and problems were found with all five (Residents #41, #7, #51, #27 and #8). The census was 94. Review of the facility's undated Weight Monitoring policy, showed the following: -Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; -Weight can be a useful indicator of nutritional status. Significant or unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem; 1. The facility will utilize a systematic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors; b. Evaluating/analyzing the assessment information; c. Developing and consistently implementing pertinent approaches; d. Monitoring the effectiveness of interventions and revising them as necessary; 2. A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status; 3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences; 4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status; 5. A weight monitoring schedule will be developed upon admission for all residents; 6. Weight analysis: The newly recorded weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in 1 month (30 days); b. 7.5% change in 3 months (90 days); c. 10% change in 6 months (180 days); Though a significant weight change may not occur, the resident may be identified as below ideal body weight by the Registered Dietician or designee; 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions; b. The physician should be encouraged to document the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] c. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed; d. If the interdisciplinary team desires to explore specific meal consumption for the resident, the Registered Dietician, Dietary Manager or the nursing department may initiate the process; e. The Registered Dietician or Dietary Manager should be consulted to assist with interventions, actions are recorded in the nutrition progress notes; f. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate; g. The interdisciplinary plan of care communicates care instructions to staff. Review of the facility's undated Therapeutic Diet Order policy, showed: -Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences; -Definitions: Therapeutic Diet is a diet ordered by a physician, or delegated registered or licensed dietician, as part of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] -Policy Explanation and Compliance Guidelines: Each resident's nutritional status is assessed by the interdisciplinary team in accordance with assessment policies; -Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: -Inadequate nutrition; -Nutritional deficits; -Weight loss; -Medical conditions such as diabetes, renal disease, or heart disease; -Swallowing difficulty; -The reason for therapeutic diets is to be documented in the medical record and/or indicated on the resident's comprehensive plan of care. All diet orders are to be communicated to the dietary department in accordance with facility procedures; -Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. 1. Review of Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/5/21, showed: -admitted [DATE]; -Adequate hearing; -Adequate vision; -Makes self understood; -Ability to understand others: Understands, clear, comprehension; -Cognitively intact; -No rejection of care; -Required extensive assistance of one person for bed mobility; -Required extensive assistance of one person for transfers and toilet use; -Required supervision, set up help only for eating; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, showed: Focus Included: -Risk for malnutrition; -Goals included his/her nutritional needs would be met; -Interventions included: -Complete mini nutritional evaluation; -If malnourished, consult dietician; -If results indicate risk, consult dietician; -If results are normal, monitor intake and weights. Review of the resident's mini nutritional assessment, dated 9/17/21, showed the following: -Weight 197 pounds (lbs); -Height 71 inches; -No weight loss in three months; -Score of 11, at risk for malnutrition; -No assessment documented after 9/17/21. Review of the resident's weights, showed the following: -On 10/27/21: 197.0 lbs; -On 11/5/21: 193.0 lbs; -On 11/10/21: 191.0 lbs; -On 11/17/21: 184.0 lbs. Review of the resident's progress notes, showed the following: -On 11/22/21 at 12:05 P.M., physician note: Resident states he/she does not like food; -On 11/23/21 at 8:40 P.M., staff noted no recent weight loss; -On 11/30/21 at 7:17 P.M., physician note: Chief complaint is abnormal weight loss, 5% weight loss. Recommendation: Weekly weights and health shakes two times a day; -No registered dietician notes documented. Review of the written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 12/1/21 at 8:20 A.M., showed the resident was served breakfast in the dining room by staff. The breakfast tray included one sausage patty, one pancake with syrup and one bowl of raisin bran. The resident had limited use of his/her right arm and needed assistance to cut up his/her pancake. The staff member helped cut up his/her pancake, but not the sausage. The staff asked the resident if he/she wanted cereal or oatmeal. He/she asked for milk for the cereal. The staff gave him/her milk and he/she struggled to open it and poured some of it in his/her cereal and drank the rest. He/she ate the pancake and the cereal, but left the sausage. He/she was given a glass of water and no juice. He/she was not offered a shake or any more food. He/she finished the meal and went back to his/her room. During an interview on 12/1/21 at 8:55 A.M., the resident said staff do not give him/her enough to eat. The pancake was hard and sometimes the staff do not cut his/her food and he/she cannot eat it. They get busy so he/she does without. He/she likes over easy eggs but they only serve scrambled eggs. They are not offered any alternatives at breakfast. Every once in a while they offer ice cream. He/she is losing weight due to the food not being good. No one has talked to him/her about supplements. He/she talked to a dietician when he/she was in the hospital and they put him/her on health shakes, but they were stopped when he/she came back to the facility. He/she would drink shakes if they were offered to him/her. He/she loves raisin bran cereal, but it is usually not offered to him/her in the mornings. Most mornings, staff do not assist him/her with his/her meals so he/she cannot eat everything. He/she needs help opening cartons, condiment packs and cutting up things. Review of a nutritional care form sent from the registered dietician, dated 12/2/21, showed the following: -Slight weight loss; -Change order to weekly weights x 4. Review of the resident's meal ticket for 12/2/21, showed no health shakes documented for breakfast, lunch or dinner. Observation on 12/2/21 at 8:30 A.M., showed staff served the resident with one glass of juice, one piece of toast and no butter, one scoop of scrambled eggs and one bowl of oatmeal. The resident asked for a health shake and the staff member got one and sat it on the table without opening it. The resident struggled to open it and spilled some of it on the table when pouring it into a glass. Observation on 12/2/21 at 12:50 P.M., showed staff served the resident a carton of 2% milk, a glass of water, one helping of rice with jambalaya over it, one piece of bread with a jelly packet and one slice of cake. He/she did not get a health shake. Review of the resident's electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -8/23/21: Regular diet, regular texture and regular consistency; -12/2/21: Obtain weekly weights x 4 weeks then monthly thereafter unless directed otherwise; -No order for supplements. Observation on 12/6/21 at 7:45 A.M., showed certified nurse's aide (CNA) K weighed the resident. The resident weighed 170 lbs. During an interview on 12/6/21 at 11:05 A. M, the Director of Nursing (DON) said they discuss resident weights every week at the at-risk meeting. If there is a concern, they notify the registered dietician. The resident was in the hospital in 9/21 and they thought some of his/her weight loss resulted from that hospital visit. They talked about his/her weight loss the prior week. The resident was down 7 lbs on 11/24/21 and she asked the nurse practitioner (NP) to see him/her. The registered dietician absolutely should have been seeing him/her, but did not attend the meeting. During an interview on 12/6/21 at 11:25 A.M., the NP said he/she saw the resident on 11/30/21 for weight loss. He/she had a 5% weight loss since he/she returned from the hospital. The NP placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse was supposed to put it in the resident's electronic record, but it did not get done. She did not know the resident had lost more weight. During an interview on 12/7/21 at 10:25 A.M., the registered dietician said she thought there was a note in the resident's chart to order health shakes. She did not remember discussing him/her prior to 12/2/21. 2. Review of Resident #41's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Adequate hearing; -Adequate vision; -Usually understood; -Usually understands others; -Cognitively intact; -No rejection of care; -Required extensive assistance of one person for bed mobility; -Required extensive assistance of one person for transfers and toilet use; -Eating: Independent; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), dysphasia (loss of or deficiency in the power to use or understand language as a result of injury to or disease of the brain), [CONDITION(S)], seizures, chronic obstructive pulmonary disease ([CONDITION(S)], lung disease) and vitamin deficiency. Review of the resident's care plan, showed: Focus included: -At risk for malnutrition; -Goals included his/her nutritional intake will meet metabolic needs; -Interventions included: -Consult dietician; -Educate resident to avoid fluid intake with meals and instead encourage fluid between meals; -Educate resident to consume high calorie foods first; -Encourage frequent small meals; -Encourage resident/representative participation in meal planning; -Ensure resident is in proper position for eating; -Obtain weights as ordered. Review of the resident's weights, showed the following: -On 9/22/21: 159.0 lbs; -On 9/30/21: 164.0 lbs; -On 10/8/21: 160.0 lbs; -On 10/13/21: 158.0 lbs; -On 10/20/21: 156.0 lbs; -On 10/27/21: 153.0 lbs. Review of the resident's mini nutritional assessment, dated 11/2/21, showed the following: -Most recent weight 156 lbs; -Height 71 inches; -Resident did not know if weight loss in three months; -Bed or chair bound; -Mild dementia; -Score of 8, at risk for malnutrition; -No assessment documented after 11/2/21. Further review of the resident's weights, showed the following: -On 11/5/21: 154.0 lbs; -On 11/10/21: 150.0 lbs; -On 11/17/21: 152.0 lbs. Review of the resident's progress notes, showed the following: -On 11/30/21 at 7:17 P.M., physician note: Chief complaint is abnormal weight loss, 5% weight loss. Recommendation: Weekly weights and health shakes two times a day; -No registered dietician notes documented. Review of the written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's e-POS on 12/1/21 at 2:00 P.M., showed no documentation of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a nutritional care form sent from the registered dietician, dated 12/2/21, showed the following: -Weight progress note. Consult; -Diet order - Change to continue house shakes two times a day. Review of the resident's meal tickets, showed large portions for all meals. Observation on 12/2/21 at 8:30 A.M., showed staff served the resident one cup of coffee, one glass of juice, one piece of toast with no butter, one scoop of scrambled eggs and one bowl of oatmeal. This was the same meal served to all residents on a regular diet. He/she did not get a health shake. Observation on 12/2/21 at 12:50 P.M., showed staff served the resident one cup of coffee, one glass of koolaide, one serving of rice with jambalaya over it, one piece of bread and one piece of cake. This was the same meal served to all residents on a regular diet. He/she did not get a health shake. Observation on 12/3/21 at 8:25 A.M., showed staff served the resident one scoop of scrambled eggs, 2 pieces of bacon, one piece of toast with a jelly packet, one small bowl of oatmeal, one cup of coffee, one cup of orange juice and a health shake. Except for the health shake, this was the same meal served to all residents on a regular diet. During an interview on 12/6/21 at 12:35 P.M., the resident said sometimes he/she would get a shake sometimes not. It depends on the staff delivering the food. Residents never get extra portions if they eat in their rooms and most of the time there are no extra portions in the dining room because they need the food for hall trays. You can get a substitute if you give them notice, but they serve what is on the menu so you can't let them know you don't want what they are serving until it is too late. The food is terrible. It is always cold by the time the hall tray gets to the rooms. During an interview on 12/7/21 at 10:30 A.M., the registered dietician said she thought there was a note in the resident's chart about an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of Resident #7's significant change MDS, dated [DATE], showed: -admitted [DATE]; -Adequate hearing; -Vision severely impaired - no vision or sees only light, colors or shapes, eyes do not appear to follow objects; -Clear speech - distinct intelligible words; -Makes self understood; -Ability to understand others: Understands - clear comprehension; -Cognitively intact; -No rejection of care; -Required extensive assistance of one person for bed mobility; -Total dependence on two (+) persons for transfers and toilet use; -Total dependence on one person for dressing, personal hygiene and bathing; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan in use during the survey, showed: Focus included: -Impaired visual function, diabetes mellitus, Hospice due to unintentional weight loss, activity of daily living deficit; -Interventions Include: -Dietary consult for nutritional regimen; -Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, and compliance with nutritional plan; -Able to feed self; -Requires staff assistance setting up meals; -The care plan did not show cheesy eggs, health shakes, super cereal, snacks between meals or whole milk as interventions. Review of the resident's weights, showed: -6/1/21: 139 lbs; -No July weight recorded; -8/4/21: 137.0 lbs; -9/1/21: 134 lbs. Review of the resident's POS, showed: -9/4/21: Regular diet, regular texture and regular consistency. Whole milk with all meals, super cereal and cheesy eggs with breakfast. Health shakes three times a day. Snack three times a day between meals. Review of the resident's nutrition/dietary notes, showed: -9/23/21 at 2:16 P.M.: Weight 136 lbs., more stable past two months following a history of loss. On a regular diet with house shakes with meals and fortified foods. Nutrition interventions are appropriate and supportive of estimated needs; Further review of the resident's weights, showed: -10/8/21: 136 lbs; -11/5/21: 120 lbs; -11/10/21: 100.0 lbs; -11/23/21: 103.0 lbs. Review of the resident's nutrition/dietary notes, showed: -11/24/21 at 11:37 A.M.: Resident continues with unplanned weight loss down to 103 lbs. On a regular diet with whole milk with meals, fortified foods, snacks and shakes three times a day. Able to make nutrition needs known. Has agreed to a hospice evaluation due to decline. Would continue nutrition interventions which more than support estimated needs. Resident does not want a tube feeding (a tube inserted through the abdomen into the stomach to deliver medication, hydration and nutrition). Observation and interviews on 12/1/21 at 8:55 A.M., showed the resident was served breakfast in bed by staff. The breakfast tray included one orange juice, one coffee, one bowl of rice krispies with 2% milk, one pancake, one sausage patty and one small bowl of oatmeal. CNA O said it was oatmeal and not super cereal. The breakfast tray did not include super cereal or cheesy eggs. During an interview, the resident shrugged his/her shoulders when asked if he/she ever received super cereal and cheesy eggs for breakfast. He/she said he/she was not sure and he/she eats what they bring. The resident fed him/herself and ate 100%. Review of the resident's menu slip served with the breakfast tray, showed cheesy eggs, health shakes, super cereal and whole milk. 4. Review of Resident #51's medical record, showed: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -A physician order, dated 11/21/20, for regular diet, regular texture with super cereal and cheesy eggs at breakfast, and power potatoes, power pudding, and ice cream at lunch/supper. Health shakes three times daily. Review of the resident's weights, showed: -On 7/21/21, weight of 117.0 lbs; -On 9/1/21, weight of 100.0 lbs. Review of the resident's dietician note, dated 9/23/21, showed the resident noted with significant weight loss this month, to 100 lbs. in two weeks. On a regular diet with health shakes with meals, good intake reported. No wounds noted. No labs for review. Would add cheesy eggs at breakfast and power potatoes with lunch and supper. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Required limited assistance of one person physical assist for eating; -Weight of 104 lbs. Review of the resident's care plan, dated 10/28/21, showed: -Focus: Resident has impaired nutrition, altered nutritional status; -Goal: Resident's nutritional intake will meet metabolic needs; -Interventions: Assist with meals (feed/set-up) as needed. Consult a dietician per order. Consult occupational therapy for adaptive devices, per order. Consult speech therapy if suspected swallowing issues. Encourage frequent, small meals. Encourage intake of nutritional supplements between meals; -The care plan did not show the resident should receive supplemental food items with meals, in accordance with his/her physician orders. Review of the resident's meal tickets, showed: -Breakfast preferences: cheesy eggs, health shakes, super cereal; -Lunch preferences: health shakes, ice cream, power potatoes, power pudding; -Dinner preferences: health shakes, ice cream, power potatoes, power pudding. Observation on 11/30/21 at 8:53 A.M., showed the resident was served one piece of toast, two strips of bacon and one hard-boiled egg for breakfast. The resident was not served cheesy eggs or super cereal. The resident fed him/herself and ate 100% of his/her meal. Observation on 12/1/21 at 12:40 P.M., showed the resident was served ham, mixed beans, bread and lemon cake. The resident was not served power potatoes, power pudding, or ice cream. The resident fed him/herself and ate 100% of his/her meal. Observation on 12/3/21 at 8:58 A.M., showed the resident was served one piece of toast, two pieces of bacon and scrambled eggs. The resident was not served cheesy eggs or super cereal. The resident fed him/herself and ate 100% of his/her meal. Observation on 12/6/21 at 12:30 P.M., showed the resident was served beef, shredded potatoes and bread. The resident was not served power potatoes, power pudding or ice cream. The resident fed him/herself and ate 100% of his/her meal. During an interview on 12/6/21 at 7:25 A.M., CNA K said the resident has early Alzheimer's disease and has been declining a lot over the past year. He/she used to not eat well and had some weight loss. The resident started eating better again and now consumes about 70 to 80% of his/her meals. He/she is supposed to get supplemental items due to the weight loss, including ice cream. The resident meal tickets show what supplemental items they are supposed to receive. Dietary is responsible for putting resident meal trays together and they should make sure the residents get the items they need to address weight loss. During an interview on 12/6/21 at 8:56 A.M., CNA DD said the resident eats good, but does not gain weight. He/she had some weight loss a while ago, but not recently. If the resident acts hungry, staff should give him/her another plate. To the CNA's knowledge, the resident does not have any food allergies. Food allergies and orders for special items, like ice cream, are documented on resident meal tickets. Dietary puts resident meal trays together and they should make sure residents are served what they are supposed to. Supplemental items like ice cream or cheesy eggs are important because they help keep residents' weight up. 5. Review of Resident #27's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated 7/8/21 for mechanical soft texture diet, regular consistency; -An order, dated 7/8/21 for aspiration precautions. Review of the dietician progress note, dated 9/23/21 at 12:10 P.M., showed the resident continued on a mechanical soft diet. Fair to good intake. Weight loss continues down to 172 pounds. Recommend double meat at lunch and dinner and house supplements with lunch. Further review of the physician orders, showed no orders to increase amount of meat at lunch and dinner or the addition of house supplements with lunch. Review of the quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -No behaviors -Received hemodialysis (used to treat end stage kidney disease, filtering the blood of impurities); -Required staff assistance with all care; -Staff provided meal set up and supervision; -Able to feed self; -Experienced a 5% weight loss in the last month or 10% in the last six months; -Not on a physician prescribed weigh loss regimen. Review of the resident's care plan, dated 10/11/21, showed: -Focus: The resident experienced an unplanned/unexpected weight loss; -Goal: The resident will maintain his/her current weight without weight loss; -Interventions: Staff alert the dietician if the resident's consumption is poor for more than 48 hours, bring the resident to the dining room for monitoring and assistance, provide supplements as ordered, if weight decline persists, notify the physician and dietician, monitor and evaluate any weight loss, obtain weekly weight as ordered. Further review of the dietician progress notes, dated 10/21/21 at 11:36 A.M., showed the resident's weight stable at 177 pounds, past three months following loss. Received mechanical soft diet, large meat portions and house supplements with lunch. Continue with nutrition orders and monitor; Review of the weekly weights, showed: -On 11/5/21: 180.0 pounds; -On 11/10/21: 174.0 pounds; -On 11/17/21: 170.0 pounds. Further review of the dietician progress notes, showed: -On 11/24/21 at 9:47 A.M., the resident continues on a mechanical soft diet, large meat portions and house shakes twice a day. Current weight 170 pounds and stable overall. Observation and interview on 11/24/21 at 12:54 P.M., showed the resident sat in the dining room. He/she had three whole chicken tender pieces on the plate, whole pinto beans. The served food was not mechanical soft consistency. The resident said he/she does not get his/her mechanical soft diet at every meal or the supplement shake. The resident had a stroke and it is difficult to open the shake if staff provided the shake to him/her. Observation on 12/6/21 at 12:22 P.M., showed the resident in the main dining room. He/she did not receive a house supplement with his/her lunch meal. 7. Review of Resident #8's nutrition/dietary note, dated 2/18/21 at 4:57 P.M., showed: -Resident readmitted from the hospital on 1/28/21 with new orders for [MEDICATION(S)] (an antidepressent sometimes used as an appetite stimulant) and weekly weights. Currently receiving speech therapy. New order for ice cream three times a day added today. Message left to update next of kin with new interventions; -No further dietary notes in the resident's medical record. Review of the resident's electronic medical record, showed: -An order, dated 2/18/21, for ice cream three times a day with meals; -An order, dated 2/18/21, for health shakes; -An order, dated 3/2/21, for a regular diet, mechanical soft texture (ground meats), regular consistency; -An order, dated 3/3/21, for super cereal and cheesy eggs for breakfast, power potatoes for lunch and dinner, large portions and large desserts. Review of the resident's care plan, updated on 11/9/21, showed: -Focus: The resident has impaired nutrition; -Goals: The resident's nutritional intake will meet metabolic needs; -Interventions: Encourage intake of nutritional supplements between meals. Is on a mechanical soft, receives super cereal, cheesy eggs at breakfast, power potatoes at lunch and supper, health shakes three times per day, ice cream three times a day with meals, larger portions and dessert. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Exhibited no behaviors; -Required limited assistance of one staff for eating; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Weight of 114.0 Pounds. Review of the resident's weight summary, dated 11/17/21 at 2:05 P.M., showed a weight of 116.0 pounds. Review of the resident's meal ticket, showed the resident was to receive super cereal, cheesy eggs and power potatoes and large portions. Observation on 11/30/21 at 8:17 A.M., showed staff served the resident breakfast that included one piece of toast, one hard boiled egg, mechanical soft sausage (all were observed to be regular portion size when compared to other residents). The resident did not receive super cereal or cheesy eggs. The resident fed him/herself breakfast. Observation on 12/1/21 at 8:47 A.M., showed the resident sat in his/her wheelchair in the dining room and ate breakfast. The meal consisted of one serving of pancakes, one serving of oatmeal, a serving of mechanically soft sausage, one glass of juice, water and one vanilla health shake. No super cereal, cheesy eggs or power potatoes were served. Observation on 12/1/21 at 12:50 P.M., showed the resident sat in his/her wheelchair in the dining room and ate lunch. The meal consisted of a serving of mechanically soft meat, one slice of bread, a serving of vegetables, a serving of steamed zucchini and a glass of water. No large portions, health shake or ice cream were present with the meal. Observation on 12/6/21 at 7:38 A.M., showed CNA K weighed the resident. The resident weighed 115.8 pounds. Review of the resident's meal ticket, showed he/she was to receive super cereal, cheesy eggs and power potatoes and large portions. Observation on 12/6/21 at 8:45 A.M., showed the resident sat in his/her wheelchair in the dining room and ate breakfast. The meal of one serving of eggs, one biscuit, one scoop of oatmeal, one glass of water, juice and a health shake. No super cereal, cheesy eggs, power potatoes, larger portions or ice cream was present. The resident fed him/herself and ate 100% of his/her meal. 8. During an interview on 12/6/21 at 10:40 A.M., the dietary manager said the registered dietician comes in once a month. There is a list of residents with weight issues posted in the kitchen. Cheesy eggs are scrambled eggs with two or three kinds of cheese and green peppers and onions for taste. Super cereal is oatmeal with cinnamon or sugar added to it. He makes and serves this to the whole floor three times a week. He gets his recipes from an old book and fixes it differently so the residents will like it. He just adds a little something to change it, just an additive for flavor and nutrition. Sometimes he changes the menu because he knows the residents do not like what is scheduled. He always clears this with the administrator first. He is putting a new book of recipes together. Larger portions are double sizes. Instead on one piece of toast, it would be two. Instead of one sausage patty, it would be two. The dietician notifie [TRUNCATED]

Based on interview and record review, the facility failed to ensure scheduled pain medication was available and/or administered as ordered, failed to document the reason the residents missed doses and failed to document the measures they took to obtain the medication for three of 61 sampled residents (Residents #44, #35 and #42). All three residents continued to experience pain and Resident #44 was unable to progress in physical therapy due to ongoing pain. The census was 94. Review of the facility's Review of the facility Pain Management Policy, dated 2020, showed: -The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences; -Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: -Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; -Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (after a fall, change in behavior or mental status, new pain or an exacerbation of pain); -Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences; -Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: -Change in gait (limping), skin color, vital signs (increased heart rate, respirations, and/or blood pressure), perspiration; -Loss of function or inability to perform activities of daily living (ADLs) (rubbing a specific location of the body, or guarding a limb or other body parts); -Fidgeting, increased or recurring restlessness; -Facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw); -Behavior such as: resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities; -Difficulty eating or loss of appetite; -Weight loss; -Difficulty sleeping ([CONDITION(S)]); -Negative vocalizations (groaning, crying, whimpering, or screaming); -Decline in activity level; -Skin conditions; -Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain. Descriptors include but are not limited to: -Heaviness or pressure, stabbing, throbbing, hurting or aching, gnawing, cramping, burning, numbness, tingling, shooting or radiating, spasms, soreness, tenderness, discomfort, pins and needles. Feeling rough, tearing or ripping; -Pain Assessment: The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain; -Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident: -History of pain and its treatment (including non-pharmacological, pharmacological, and alternative medicine (CAM) treatment and whether or not each treatment has been effective); -Asking the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident; -Reviewing the resident's current medical conditions (e.g. pressure injuries, diabetes with neuropathic pain, immobility, infections, amputation, oral health conditions, post [CONDITION(S)], venous and arterial ulcers, and [CONDITION(S)]); Identifying key characteristics of the pain: -Duration of pain; -Frequency; -Location; -Timing; -Pattern (e.g. constant or intermittent); -[CONDITION(S)] of pain; -Obtaining descriptors of the pain (stabbing, aching, pressure, spasms); -Identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain; -Impact of pain on quality of life (e.g. sleeping, functioning, appetite and mood); -Current prescribed pain medications, dosage and frequency; -The resident's goals for pain management and his/her satisfaction with the current level of pain control; -Physical and psychosocial issues that might be causing or exacerbating the pain; -Additional symptoms associated with pain (e.g. nausea, anxiety); -Pain Management and Treatment: -Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other healthcare professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission; -The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal; -The interdisciplinary team and the resident and/or the resident's representative will collaborate to arrive at pertinent, realistic and measurable goals for treatment; -Factors influencing the choice of treatments include: -The cause, location and severity of resident's pain; -The resident's current medical condition; -The resident's current medications; -The resident's desired level of relief and tolerance for adverse consequences (partial pain relief for fewer significant adverse consequences); -Potential benefits, risks and adverse consequences of medications; -Available treatment options. 1. Review of Resident #44's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/3/21, showed: -No cognitive impairment; -No behaviors; -Supervision with activities of daily living; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Received an as needed medication: Yes; -Presence of pain: Yes; -Pain intensity: 5 of 10. Review of the resident's verbal physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Discontinue [MEDICATION(S)] (narcotic-like pain reliever, used to treat moderate to severe pain in adults) tablet, 50 milligrams (mg), give one tablet by mouth three times a day for chronic knee pain; -Reason: Resident has to be seen by pain management for new order. Review of the resident's progress notes, showed the following: -On 9/22/21 at 3:18 P.M., an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one tablet by mouth two times a day. Seen today by the physician. At 4:06 P.M., health status note. Physician follow up note. The physician saw the resident due to a follow up related to progression of physical therapy. The resident informed the physician about the need for his/her [MEDICATION(S)] medication. Discussion done with physician about need for [MEDICATION(S)], he stated he will send a prescription. Physical therapy started on August 26, 2021. Continue with physical therapy. According to physical therapist, he/she is not progressing as well as he/she should. Review of the resident's written physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medication administration record (MAR), dated 10/1/21 through 10/31/21, showed the following for the [MEDICATION(S)]: -10/15: Administered one time at 9:00 A.M. Nothing recorded for 9:00 P.M.; -10/29: Administered one time at 9:00 P.M. Nothing recorded for 9:00 A.M.; -10/30: Administered one time at 9:00 P.M. A 9 recorded for 9:00 A.M.; -Chart codes were labeled 5=hold/see progress noted and 9= other/see progress notes. Review of the resident's progress notes for 10/1/21 through 10/31/21, showed no documentation for reason medications not administered on 10/15, 10/29 and 10/30. Review of the resident's narcotic count sheet for October 2021, showed the following: -On 10/4, no documentation of any [MEDICATION(S)] counted as administered; -On 10/8, one dose of [MEDICATION(S)] counted as administered; -On 10/14, one dose of [MEDICATION(S)] counted as administered; -On 10/17, one dose of [MEDICATION(S)] counted as administered; -On 10/21, one dose of [MEDICATION(S)] counted as administered; -On 10/22, one dose of [MEDICATION(S)] counted as administered; -No documentation of [MEDICATION(S)] counted as administered after 10/28. Review of the resident's e-POS, dated 11/1/21 through 11/30/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MAR, dated 11/1/21 through 11/30/21, showed the following for the [MEDICATION(S)]: -11/1: Administered one time at 9:00 P.M. A 9 recorded for 9:00 A.M.; -11/5: Administered one time at 9:00 P.M. A 9 recorded for 9:00 A.M.; -11/6: Administered one time at 9:00 P.M. A 5 recorded for 9:00 A.M.; -11/7: Administered one time at 9:00 P.M. A 5 recorded for 9:00 A.M.; -11/10: Administered one time at 9:00 P.M. A 9 recorded for 9:00 A.M.; -11/13: Administered one time at 9:00 P.M. A 9 recorded for 9:00 A.M.; -11/14: Administered one time at 9:00 P.M. A 9 recorded for 9:00 A.M.; -11/15: Administered one time at 9:00 P.M. A 9 recorded for 9:00 A.M.; -11/16: Administered one time at 9:00 A.M. Nothing documented for 9:00 P.M.; -11/19: Administered one time at 9:00 P.M. A 5 recorded for 9:00 A.M.; -11/26: Administered one time at 9:00 P.M. A 9 recorded for 9:00 A.M.; -11/27: Administered one time at 9:00 P.M. A 9 recorded for 9:00 A.M.; -11/28: Administered one time at 9:00 P.M. A 9 recorded for 9:00 A.M. Review of the resident's progress notes for 11/1/21 through 11/30/21, showed no documentation for a reason the medications were not administered on 11/1, 11/5, 11/6, 11/7, 11/10, 11/13, 11/14, 11/15, 11/16, 11/19, 11/26, 11/27 and 11/28. Review of the resident's narcotic sheet, showed no documentation of [MEDICATION(S)] signed out for November 2021. Further review of the resident's progress notes, showed the following: -On 11/2/21 at 4:39 P.M., Physician's note: The resident displayed left shoulder pain; -On 11/4/21 at 12:29 P.M., staff left a message to set up an appointment for pain management; -On 11/5/21 at 1:05 P.M., Physician's note: The resident displayed joint pain, left shoulder pain and ongoing right hip pain; -On 11/16/21 at 11:43 A.M., a physician's note: The resident displayed joint pain, left shoulder pain and ongoing right hip pain. Care plan: Continue with physical therapy for range of motion and strengthening exercises. [MEDICATION(S)] tablet 50 mg 1 tablet by mouth two times a day. Review of the resident's care plan, dated 11/29/21, showed: -Focus: Has chronic pain related to [CONDITION(S)]; -Goal: Resident will report satisfactory pain control; -Interventions/Tasks: Administer prescribed medication before activity and therapy. Educate resident/representative on prescribed analgesics and/or anti-[CONDITION(S)] medications. Establish a pain management treatment plan. Evaluate for non-verbal indicators of pain. Evaluate pain. Monitor for factors/activities that precipitate or aggravate pain. Monitor participation in therapies for decline or refusal. Review of the resident's MAR, dated 12/1/21 through 12/31/21, showed on 12/1/21 at 9:00 A.M., the resident did not receive his/her 9:00 A.M. dose of [MEDICATION(S)]. Review of the resident's progress notes for 12/1/21 through 12/31/21, showed no documentation for staff not administering the medication on 12/1/21. During an interview on 11/30/21 at 10:55 A.M., a pharmacy staff member said they last filled an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . They had not received any new orders from the resident's physician for [MEDICATION(S)] since that date. During interviews on 11/30/21 at 10:10 A.M. and 12/1/21 at 1:40 P.M., Nurse J said he/she called the pharmacy on 11/29/21 and the pharmacy did not say anything about needing a prescription from the physician. The nurse knew the physician wanted the resident to be seen at the pain clinic before he would write another prescription and had made an appointment for the resident but they had issues with transportation and had not been able to get the resident to his/her appointment. Nurse J thought he/she talked to the resident's physician or someone in the physician's office about sending a new prescription but did not have any documentation of it. During an interview on 11/30/21 at 10:45 A.M., the resident said he/she is in pain all of the time. It was worse in the mornings when staff got him/her up. The staff give him/her a hard time whenever he/she asks for something for pain. The resident had been asking everyone and no one would help him/her. He/she was supposed to be going to physical therapy, but it hurt too much to do the exercises without his/her pain medication. The resident was not moving as well as he/she used to because of the pain. Review of the resident's progress notes, dated 12/1/21 at 10:19 A.M., showed the nurse contacted the pharmacy to inquire about the resident's [MEDICATION(S)]. The pharmacy told the nurse a script was needed. The nurse told the pharmacy a call was placed to them yesterday and nothing was said about needing a script and reminded them them they have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/2/21 at 7:45 A.M., certified medication technician (CMT) T said the resident complained of pain every day. He/she knew the resident had been out of his/her [MEDICATION(S)] for awhile. The resident would ask for it and CMT T would not be able to give it to him/her because it had not been approved by the resident's physician. During an interview on 12/3/21 at 9:15 A.M., the PT director said the resident complained of pain every day he/she was in therapy. They were unable to work with the resident's right shoulder or hip in the past because progress ceased due to the pain. During an interview on 12/3/21 at 1:20 P.M., Nurse AA said the resident complains of pain a lot in his/her knees. During interviews on 12/1/21 at 10:00 A.M. and on 12/7/21 at 1:40 P.M., the Director of Nursing (DON) said the resident ran out of medication in 10/21. They had called the pharmacy about a refill, but the pharmacy needed a prescription from the physician. She had not called the physician to find out about refilling the prescription as that was the pharmacy's responsibility. She called the pharmacy on 11/20/21 and found out the last time the prescription was filled was on 9/22/21. If the resident was without his/her pain medication for a long time, the nurse should have called the physician to find out about writing a new prescription. Staff should not have been documenting they were giving the medication if they were not giving it and they should have been documenting the reason for not giving it on the MAR and in the resident's progress notes. During an interviews on 11/30/21 at 11:35 A.M., and on 12/7/21 at 9:50 A.M., the nurse practitioner said the resident complained to her a few weeks ago about needing his/her pain medication refilled. The nurse practitioner cannot write a prescription for a narcotic, so she left a message for the resident's physician and let the nurse know. If the resident continued to complain of pain, the staff should have continued to try and contact the physician and get the prescription filled. During an interview on 12/7/21 at 10:25 A.M., the resident's physician said he did not know the resident was still waiting to be seen at the pain clinic and was without his/her pain medication. The staff should have contacted his office to let him know there was a hold up with the appointment and he would have refilled the prescription. 2. Review of Resident #35's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Independent with all activities of daily living (ADLs); -Received scheduled pain medication and pain medication as needed (PRN), yes; -Received non-medication intervention for pain, no; -Pain assessment: Pain presence, yes/frequently; -Medications received/number of days received pain medication during the last seven days, seven; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, showed: -Focus: Acute/chronic pain; -Interventions: Evaluate pain, establish a pain management treatment plan, and monitor factors that precipitate or aggravate pain; -Focus: Resident has the potential to become physically/verbally aggressive due to poor impulse control; -Interventions: Access and anticipate needs (food, thirst, pain). Intervene before agitation escalates, when resident becomes agitated, engage calmly in conversation, if response is aggressive, staff to walk away and approach later. Review of the resident's e-POS, showed; -An order, dated 12/4/20, for acetaminophen 325 mg, give two tablets by mouth as needed for pain or elevated temperature, three times a day as needed (PRN); -An order, dated 12/4/20, for [MEDICATION(S)] ointment 5%, apply to affected painful areas topically (on the skin), every eight hours as needed for pain related to unspecified [CONDITION(S)]; -An order, dated 12/7/20, may crush medications/put in applesauce if appropriate; -An order, dated 12/15/20, for [MEDICATION(S)]-acetaminophen tablet, give one tablet by mouth every eight hours as needed for pain; -An order, dated 2/6/20, for [MEDICATION(S)] capsule, 200 mg, give one tablet by mouth one time a day for chronic pain; -An order, dated 2/24/20, for Tylenol 8 Hour Arthritis Pain Tablet Extended Release (Acetaminophen ER). Give one tablet by mouth every 12 hours PRN for pain. Review of the resident's MAR, showed: -On 3/1/21 through 3/22/21, showed no documented pain levels, no PRN pain medication documented as administered; -On 3/26 through 3/31/21, showed no documented pain levels, no PRN pain medication documented as administered; -On 4/1/21 through 4/16/21, showed no documented pain levels, no PRN pain medication documented as administered. Review of the resident's nurse's progress notes, dated 4/22/21 at 2:05 P.M., showed the resident attempted to hide narcotic pain medication in face mask in front of this nurse and assistant director of nursing (ADON). This nurse took the pain medication from the mask and destroyed it. Resident was told that his/her actions will be told to pain management clinic. During an interview on 12/7/21 at 10:11 A.M., Nurse S said other residents told staff the resident exchanged pills with other residents when he/she went outside to smoke. Nurse S said he/she witnessed the resident spit his/her narcotic pill into his/her facemask and it fell out. Nurse S said the resident was not in pain, but he/she would come by the desk every eight hours and ask for pain medication. If he/she knew a nurse was on to him/her, the resident would swallow his/her medication. Nurse S gave the resident his/her pain medication when he/she asked for it, and he/she may be guilty of not documenting the administration in the electronic record, but he/she did document in the narcotic count sheets. Review of the resident's closed medical record, showed no documented narcotic count sheets. During an interview on 12/7/21 at 12:21 P.M., the staffing coordinator said he/she was unable to locate the resident's narcotic count sheets. Review of the resident's History and Physical, dated 4/28/21, showed: -Resident was sent to the hospital on 4/24/21, with swollen, erythematous (abnormal skin redness), right elbow pain and fever of 100 degrees. Resident returned within 24 hours with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she only complains of pain with range of motion (ROM); -Resident reported intermittent pain, occasional headache (few times a week), back pain and arthralgia (joint stiffness). Further review of the resident's MAR, showed; -On 4/20/21 through 4/30/21, no documented pain levels, no PRN pain medication documented as administered; -On 5/1/21 through 5/4/21, no documented pain levels, no PRN pain medication documented as administered. Review of the resident's nurse's progress notes, showed; -On 5/6/21 at 3:36 P.M., Nurse S documented the resident was very aggressive with this nurse while asking for a PRN pain pill. This nurse asked resident not to speak with him/her in that manner, resident then cursed this nurse and threatened to shoot him/her at the nurse's station. This nurse then told resident to leave the nurses station. This nurse then went to report to the ADON resident's actions and resident was present, and stated he/she would shoot up the whole building; -On 5/6/21 at 4:23 P.M., the ADON documented at approximately 3:30 P.M., the resident came down to the lobby and complained he/she wanted to leave against medical advice (AMA), because the nurse would not give him/her his pain medication. Resident did not have a current script from the physician and does not have any in the building. Resident then stated he/she was going to leave AMA, buy a machine gun and shoot everyone up. Officers were contacted and arrived with emergency medical services (EMS) at approximately 4:00 P.M. Psych was made aware of behaviors. Resident requested to go the to the hospital and was sent to the emergency room ; -On 5/7/21 at 8:31 A.M., social worker went to the basement and found resident speaking with the ADON about his/her pain medication. Resident was upset he/she was not getting his/her medication and stated he/she was going to leave AMA. While waiting for the police, social worker spoke with the resident and he/she was calm. Discussed with resident some of the issues with his/her pain medication, scripts from doctor, his/her cheeking medications (hiding inside cheek), and some trading of medications in his/her past. Resident said he/she does not do that. Resident was calm when police arrived, after discussion with the police, he/she was transported to the hospital for pain medication. During an interview on 12/7/21 at 9:51 A.M., the nurse practitioner said when there are concerns with a resident cheeking their medications, they can have an order to crush medications, especially pain medications. She said it was not nice to hold pain medication because people believe they have an addiction. They have pain and the pain medication should be given. She expected pain medication to be given and documented when given. During an interview on 12/7/21 at 10:43 A.M., the physician said if the resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of Resident #42's annual MDS, dated [DATE], showed: -admitted on [DATE]; -Understood and able to understand others; -No behaviors; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Scheduled pain regimen: Yes; -Received an as needed medication: Yes; -Presence of pain: Yes; -Pain frequency: Yes; -Pain intensity: 4 of 10. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MAR, dated 10/1/21 through 10/30/21, showed the following for [MEDICATION(S)]: -10/1, 10/26, 10/29 and 10/30: A 5 recorded for 9:00 P.M.; -10/2, 10/6, 10/9, 10/10 and 10/21: Nothing documented; -10/3, 10/4, 10/5, 10/7, 10/8, 10/11, 10/12, 10/13, 10/14, 10/15, 10/16, 10/17, 10/18, 10/19, 10/20, 10/21, 10/22, 10/24, 10/25, 10/27, 10/28: Recorded as administered; -10/14: A 9 recorded for 9:00 P.M. Review of the resident's progress notes for 10/1/21 through 10/31/21, showed the following: -No documentation for reason medications not administered; -No documentation of why the medication was not ordered or received from the pharmacy; -No documentation of notification to the resident's physician about the resident not receiving the medication. Review of the resident's progress notes, showed the following: -On 10/9/21 at 2:52 P.M., the resident had a fall on night shift. Complained of left hip pain; -On 10/10/21 at 9:34 A.M., resident complained of pain, unable to get out of bed. Resident in pain. Pain with movement. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -On 11/5/21, discontinue [MEDICATION(S)] capsule 150 mg, give 150 mg, by mouth at bedtime for pain; -On 11/6/21, start [MEDICATION(S)] capsule 150 mg, give 150 mg, by mouth at bedtime for pain. Review of the resident's MAR, dated 11/1/21 through 11/30/21, showed the following for [MEDICATION(S)]: -On 11/1: A 6 recorded for 9:00 P.M. - On 11/2, 11/3, 11/4, 11/6, 11/17, 11/22 and 11/29: Nothing documented; - On 11/7, 11/11, 11/15, 11/18, 11/21 and 11/24: Recorded as administered; - On 11/8, 11/9, 11/10, 11/12, 11/13, 11/14, 11,16, 11/19, 11/20, 11/23, 11/25, 11/26, 11/28: A 5 recorded for 9:00 P.M.; -On 11/20, 11/27 and 11/30: A 9 recorded for 9:00 P.M. Review of the resident's progress notes for 11/1/21 through 11/30/21, showed the following: -No documentation for reason medications not administered; -No documentation of why the medication was not received from the pharmacy; -No documentation of notification to the resident's physician about the resident not receiving the medication. Further review of the resident's progress notes on 12/1/21 at 3:40 P.M., showed the nurse practitioner saw the resident related to a question about his/her medication. The resident had not been taking his/her [MEDICATION(S)] for the last two months. He/she complained of hip pain but Tylenol worked. The [MEDICATION(S)] was discontinued. During an interview on 12/7/21 at 9:45 A.M., the resident said he/she used to ask for his/her pain medication at bedtime all the time when he/she first came in, but it did not do any good because they never had it. The pain made it hard to sleep at night. During an interview on 12/7/21 at 9:55 A.M., the nurse practitioner said the staff first made her aware the resident was not receiving his/her pain medication on 12/1/21. The staff should have let her or the resident's physician know if the pharmacy did not send the resident's medication. During an interview on 12/7/21 at 10:30 A.M., the resident's physician said he did not know the resident was without his/her [MEDICATION(S)] for two months. No one from the facility let him know the facility had not received his/her medication. The staff should have called him and let him know if there was a problem with the resident getting his/her medication. 5. During an interview on 12/7/21 at 1:54 P.M., the administrator said she was not sure where the narcotic sheets were located and medical records should be kept on file for seven years. She said the administration of medications should be documented on both the electronic record as well as on the narcotic sheets and medications should be administered as ordered. MO 751 MO 795

Based on observation, interview and record review, the facility failed to maintain an infection control program during a Coronavirus disease 2019 pandemic, to provide a safe environment for residents, when the facility failed to ensure residents who tested negative for COVID-19 did not share a room with a resident that tested positive. Staff placed the positive residents on transmission based precautions, but left them in the same room with their roommate, putting the roommates at risk from [MEDICAL CONDITION]. Of the 22 residents who recently tested positive for COVID-19, two were sampled and both residents had a roommate who tested negative for COVID-19. (Residents #1, #4, #2 and #3) The census was 101. The administrator was notified on 12/17/20 at 1:30 P.M., of an Immediate Jeopardy (IJ) which began on 11/25/20. The IJ was removed on 12/17/20, as confirmed by surveyor onsite verification. Review of the Centers for Disease Control and Prevention (CDC) Preparing for COVID 19 in Nursing Homes guidelines, updated 11/20/20, showed: -Given their congregate nature and resident population served (older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19. As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and health care personnel (HCP); -Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19; -Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use; -Have a plan for how residents in the facility who develop COVID-19 will be handled: -Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Cloth face coverings are not considered Protective Personal Equipment (PPE) and should only be worn by HCP for source control, not when PPE is indicated; -Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them); -Additional information about cohorting residents and establishing a designated COVID-19 care unit is available in the Considerations for the Public Health Response to COVID-19 in Nursing Homes; -The facility is to provide supplies necessary to adhere to recommended infection prevention and control practices. The facility should position a trash can near the exit, inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room. Review of the CDC Responding to Coronavirus (COVID-19) in Nursing Homes: Considerations for the Public Health Response to COVID-19 in Nursing Homes guidelines, updated 4/30/20, showed: Resident with new-onset suspected or confirmed COVID-19 -Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. --Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). --If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. -If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. -Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible,should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2, 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). --Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. Review of the facility's COVID-19 Policy and Procedure, undated, showed: -Policy: It is the policy of the facility to develop and implement strategies to prevent the spread of the COVID-19 within long-term care population; -Procedure: -Strategies to Prevent Spread of COVID-19: Staff are encouraged to utilize strategies used to detect and prevent the spread of other respiratory viruses, such as influenza. Should the facility become concerned that a resident, visitor or employee may be a COVID-19 patient under investigation, should contact local and/or state health department immediately for consultation and guidance; -To prevent the spread of respiratory infections within the facility: Keep residents and employees informed by describing what actions the facility is taking to protect them, including answer their questions and explaining what they can do to protect themselves and fell ow residents; -Patient Placement: - Place a patient with known or suspected COVID-19 in single patient room that has been constructed and maintained in accordance with current guidelines, if available. If one of these rooms is not available, patients requiring hospitalization should be transferred as soon as feasible to a facility where appropriate room type is available. If the resident does not require hospitalization , the resident can be placed in an appropriate room as deemed medically and socially appropriate and per recommendations of the state and local public health authorities. Pending any transfer or discharge from the facility, place a facemask on the resident and isolate him/her in a room with the door closed. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/20, showed; -Moderate cognitive impairment; -No moods or behaviors; -Independent with bed mobility, transfers and eating; -Supervision with ambulation, dressing and toilet use; -Limited assistance with personal hygiene; -[DIAGNOSES REDACTED]. Review of the resident's COVID lab results, showed: -11/25/20, negative; -11/27/20, negative; -12/2/20, positive. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -No moods and behaviors; -Extensive assistance with dressing, toilet use, personal hygiene and locomotion on the unit; -Supervision with eating; -[DIAGNOSES REDACTED]. Review of the resident's COVID lab results, showed: -11/25/20, negative; -11/28/20, negative; -12/2/20, negative. Observation on 12/3/20 at 9:41 A.M., showed Resident #1 and Resident #4 were roommates. During an interview at that time, Certified Nurse Aide (CNA) A and Nurse B said they did not know which resident was positive for COVID-19. CNA A and Nurse B said it is very important to know which residents were positive to ensure proper preventative care is given. CNA A said he/she would use full PPE when giving care to a COVID positive resident. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -No moods or behaviors; -Independent with activities of daily living (ADLs); -[DIAGNOSES REDACTED]. Review of the resident's COVID lab results, showed: -11/25/20, negative; -11/27/20, negative; -12/2/20, negative. Review of Resident #3's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Behaviors of hallucinations and delusions; -Supervision with dressing and personal hygiene and independent with other ADLs; -[DIAGNOSES REDACTED]. Review of the resident's COVID lab results, showed; -11/13/20, canceled; -11/18/20, negative; -11/25/20, positive. Observation on 12/3/20 at 11:45 A.M., showed Resident #2 and Resident #3 were roommates. During an interview at that time, CNA A and CNA C said the residents have been roommates for at least the last two months. Resident #2 is COVID negative and Resident #3 is COVID positive. They both are pretty much self care and rarely come out of their room. Resident #2 will come out and go to the vending machine then go back to his/her room. The CNAs said to their knowledge, they did not know if the facility had a COVID designated area. They would use full PPE when giving care to a COVID positive resident. During an interview on 12/17/20 at 1:35 P.M., Nurse D said according to the resident roster, Resident #2 and Resident #3 were still roommates. Observation at that time with Nurse D, showed the residents were still roommates. Nurse D confirmed this observation. 3. During an interview on 12/8/20 at 1:55 P.M., the Infection Preventionist said he/she was aware of the CDC guideline, however the negative residents who room with positive residents are assumed to be positive because of being in a close proximity. The staff should use full PPE when entering the rooms and giving care. The designated COVID area is on the second floor. During an interview on 12/3/20, the Director of Nursing said COVID negative residents stayed in the same room with a COVID positive resident because they were assumed to be positive because of the close proximity. The staff should use full PPE when giving care to either resident. During an interview on 12/17/20 at 1:36 P.M., the Infection Preventionist said he/she did not know why the residents had not been moved. He/she was aware of the CDC guidelines regarding COVID positive and negative residents not being in the same room. During an interview on 12/17/20 at 1:37 P.M., Nurse Practitioner E said there is an issue if COVID positive and negative residents are in the same room. [MEDICAL CONDITION] could be transmitted from resident to resident. During an interview on 12/17/20 at 2:20 P.M., the administrator said since Resident #2 was previously COVID positive more than 90 days ago, he/she did not need to move from the room. The administrator said she was aware of the CDC guidelines, but did not know how it applied to residents who were COVID positive more than 90 days prior. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 575

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #307) was free of significant medication errors when they failed to obtain and administer two [MEDICAL CONDITION] medications as ordered by the physician for approximately one month. The facility census was 99. 1. Review of the resident's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/4/20, showed staff assessed the resident as follows: -Cognitively intact; -Had delusions; -Rejected care; -Independent with bed mobility, transfers, walking, dressing, eating, toilet use and personal hygiene; -Continent of bowel and bladder; -diagnosed with [REDACTED]. Review of hospital discharge papers showed the following: -The resident was admitted for inpatient psychiatric treatment on 1/13/20 and discharged on [DATE]; -The admitting [DIAGNOSES REDACTED]. -The hospital [DIAGNOSES REDACTED]. -The discharge medication list included [MEDICATION NAME] (mood stabilizing and antimanic medication) 300 milligrams (mg)s by mouth twice daily and [MEDICATION NAME] (antipsychotic medication) 20 mg by mouth daily at bedtime. Review of the resident's medical record showed prescriptions, dated 2/4/20, written by the hospital psychiatrist for [MEDICATION NAME] 300 mg by mouth twice daily and [MEDICATION NAME] 20 mg by mouth daily at bedtime Review of the resident's Physician order [REDACTED]. -The resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. Review of the resident's Medication Administration Record (MAR), dated February 2020, showed staff not did transcribe the order for [MEDICATION NAME] or [MEDICATION NAME] from the POS. Review of nurses' notes, for February 2020, showed the following: -2/22/20 at 12:00 A.M. - Resident walking back and forth through the hallways hitting on doors stating she is going to wake everybody up because staff will not get him/her a soda; -2/22/20 at 1:00 A.M. - The resident continues walking the halls hitting on doors; -2/22/20 at 1:35 A.M. - The psychiatrist was called and made aware of resident's behavior. The psychiatrist gave orders to send the resident to the hospital for a psychiatric evaluation. The administrator and the resident's family were called. The ambulance transported the resident to the hospital; -2/22/20 at 1:30 P.M. - The resident arrived back to the facility by ambulance from the hospital. The resident has no new orders. Review of the resident's POS, dated 3/1/20 through 3/31/20, showed the following: -an order for [REDACTED]. -an order for [REDACTED]. Review of the resident's March 2020 MAR, on 3/4/20 at 2:30 P.M., showed the following: -an order for [REDACTED]. This medication was documented as not given twice on 3/1, once on 3/2, twice on 3/3 and once on 3/4. -Staff documented for 3/1 that the [MEDICATION NAME] was not given need to call doc for refill. -Staff documented for 3/3 that the resident refused all morning meds. -Staff documented for 3/4 that the [MEDICATION NAME] was not given needs refill/CN (charge nurse) handling. -an order for [REDACTED]. This medication was documented as given on 3/1 and 3/2. This medication was documented as not given on 3/3; -Staff documented for 3/3 that the resident refused all night meds. During an interview on 3/2/20 at 11:55 A.M., the resident said he/she has lived at the facility for about three weeks. The resident became tearful and said the facility is not giving him/her the correct medication. He/She said They are not giving me my [MEDICATION NAME] so I can't sleep and I'm not eating. Observation on 3/3/20 at 1:05 P.M., showed the resident upset in the hallway and speaking very loudly. The resident said people needed to listen to him/her, because there are people sick and dying on television. The resident walked into the dining room and went up to an unidentified staff person who was feeding another resident and begged the staff member to come back to his/her room to listen to the TV. The unidentified staff person pulled another chair up to the table and asked the resident to please sit down. The resident sat down for approximately one minute and then got back up and proceeded to go down the hallway speaking loudly about the TV talking to him/her. Observation on 3/3/20 at 1:45 P.M., showed the resident rapidly pacing through the hallways asking multiple people for batteries. The resident said if he/she got it to work then he/she could plug it into the elevator to leave. During an interview on 3/3/20 at 2:00 P.M., Licensed Practical Nurse (LPN) A said Medicaid would not pay for the resident's [MEDICATION NAME]. LPN A said if the resident was on [MEDICATION NAME] then he/she wouldn't be acting like this. Observation on 3/3/20 at 2:25 P.M., showed the resident in the phone room with the door open. The phone room was the first room down the hallway from the nurses' station. The resident was yelling into the phone that he/she was [MEDICAL CONDITION] and staff won't give him/her the correct medication. The resident yelled into the phone while sobbing, Nobody is paying attention to me! They don't care, nobody cares and I'm going crazy, because they aren't giving me my medicine! I'm going crazy, the TV is talking to me! I won't take the medicine they give me, because it's not right! Observation showed an unidentified staff person sat at the nurses' station charting. The unidentified staff person said the resident was on the phone with state and that this was the second time the resident had called them today. The unidentified staff member stated the resident had been like this since admission, but it was worse today, because the resident had refused medication the past two days. The resident yelled out the doorway of the phone room to the state surveyor and asked the state surveyor to come in and talk to the person on the phone. The resident yelled, Tell them what is happening! as he/she cried and handed the phone to the state surveyor. The resident had called the emergency mental health hotline. During an interview on 3/3/20 at 2:46 P.M., LPN A said the resident has been off [MEDICATION NAME] for about a week and they found out about three days ago. LPN A said as soon as they found out they started trying to order it. During an interview on 3/3/20 at 3:18 P.M., the pharmacist said she was not sure if she looked at the resident's chart last month, because the resident may have been admitted right after she was there to do her chart reviews. Staff told her that for the past couple of days the resident was refusing medication. The pharmacist said she would look into whether or not the resident was getting the ordered dose of [MEDICATION NAME]. During an interview on 3/3/20 at 3:52 P.M., the pharmacist said the following: -She looked for [MEDICATION NAME] for the resident in the medication cart, but did not find any. She called the person who does billing at her company who said they have not dispensed [MEDICATION NAME] or [MEDICATION NAME] to the facility for the resident, because Medicaid required additional documentation from the resident's physician since the resident was on more than six [MEDICAL CONDITION] medications. She was going to notify the administrator. During an interview on 3/4/20 at 1:45 P.M., LPN A said the following: -He/she had only worked at the facility for two weeks; -When the resident does not sleep, he/she hallucinates and is not rational; -When a resident's behavior reaches a level that he/she has to address, then he/she calls the physician and documents this in a nurse's note. If they contact a physician this should be documented in a nurse's note along with what the physician's response is; -The admission process for admission orders [REDACTED]. Staff write out the hospital discharge medication list on a POS. The nurse verifies the orders by calling the resident's attending physician at the facility. After the physician verifies the orders, the nurse writes the ordered medications on the MAR; -He/she does not think the resident received any [MEDICATION NAME] during February. The Certified Medication Technician (CMT) would be the one to give the resident [MEDICATION NAME]. The first time he/she was made aware that the resident was not receiving [MEDICATION NAME] was three days ago when CMT C told him/her about it. CMT C was comparing the February MARs to the March MARs on 2/29/20 and noticed there was an order for [REDACTED]. When CMT C found this, they faxed the order for the [MEDICATION NAME] to the pharmacy. He/she then received a call from the pharmacy saying the reason they had not filled the [MEDICATION NAME] order was that there had to be a prior authorization from the resident's physician for the medication. He/she did not notify the physician the resident was not receiving [MEDICATION NAME]; -He/she did not know the resident was not getting his/her ordered [MEDICATION NAME] until today. During an interview on 3/4/20 at 2:11 P.M., CMT C said the following: -The resident seems to be aware of the medications he/she receives. The resident kept telling staff that they were not giving him/her all of his/her medications and some days the resident would refuse medication because of this; -Once the March MARs came out, he/she noticed there was an order for [REDACTED]. During an interview on 3/4/20 at 2:45 P.M., the Administrator said the following: -They were not aware the resident was not receiving the ordered [MEDICATION NAME] and [MEDICATION NAME]. The pharmacist notified them of this yesterday evening. The pharmacist told them that they tried to contact the facility four times because Medicaid required additional documentation from the resident's physician before they would pay for the medication, but she was not aware of this until yesterday evening; -They contacted the resident's attending physician and psychiatrist today to notify them the resident had not been receiving the ordered [MEDICATION NAME] and [MEDICATION NAME] and this was the first time the physicians were made aware of this; -They contacted Medicaid today about what is required before they will pay for the [MEDICATION NAME] and [MEDICATION NAME]. Until Medicaid is able to pay for the medication the facility will pay for it. During an interview on 3/4/20 at 4:24 P.M., the attending physician for the resident said the following: -He is uncertain if he saw the resident yet or if someone else in his office had; -He does not recall if staff contacted him about [MEDICATION NAME] and [MEDICATION NAME] being unavailable for the resident; -If a medication is not available for a resident he expected staff to notify him, or the psychiatrist if it is a [MEDICAL CONDITION] medication, so a possible substitute medication can be ordered; -He cannot say for sure what effect not getting the [MEDICATION NAME] and [MEDICATION NAME] since admission had on the resident. The behaviors they told him the resident had yesterday sounded like [MEDICAL CONDITION] to him. During an interview on 3/6/20 at 10:40 A.M., LPN A said the resident never told him/her that he/she wasn't getting [MEDICATION NAME], but the resident did tell him/her that he/she wasn't getting the correct medications. During an interview on 3/6/20 at 5:30 P.M. the Administrator said the following: -When a resident is admitted to them from the hospital the admitting nurse verifies the medication list from the hospital with the attending physician. After this, the nurse writes the medication orders on the POS and also on the MAR; -If the nurse has a question about a resident's medication orders then they should contact the physician; -If the nurse calls the physician then they should document this in a nurse's note and include what they told the physician and any new orders the physician gave; -Nobody does 24 hour chart checks at the facility; -The director of nurses (DON) and quality assurance (QA) nurse review orders for new admissions and readmissions the day after admission.

Based on interview and record review, the facility failed to recognize and address the risk for the physical abuse of one resident (Resident #1, who is blind, has senile dementia and speaks/understands limited English) out of a sample of five residents. Resident #2, who has a history of physically aggressive behavior, began reacting with anger and aggression on occasions when Resident #1 wandered into the room shared by Resident #2 and Resident #3 (who also had a history of [REDACTED]. Resident #2 and Resident #3 subsequently assaulted Resident #1, inflicting a left frontal contusion, mild [MEDICAL CONDITION], as well as a contusions to the lower abdomen, lower legs, and upper right arm. The census was 94. Review of Resident #1's care plan, updated 4/1/19, showed the following; -Alert and oriented to self; -Cognitive loss related to dementia; -Extremely confused; -Risk of fear with care because he/she cannot understand or see; -Orient to surroundings, routine, activities; -Total dependence for all needs; -8/21/15, Assistance needed due to [MEDICAL CONDITION], confusion, and language barrier; -Very limited communication due to language barrier; -Use of hand gestures to communicate; -4/1/19, Assisted ambulation; -Risk of wandering due to senile dementia; -Frequent staff supervision required. Review of the resident's nurse's note, dated 4/25/19 at 5:30 P.M., showed the resident attempted to use the restroom and wandered into the adjoining room. Staff redirected the resident back to his/her room. Review of the resident's annual assessment Minimum Data Set (MDS), dated [DATE], showed the following: -Severe cognitive impairment; -Misses some part/intent of messages, but is able to understand others if prompted/given time; -Wandering not exhibited; -Severely impaired vision, no vision or sees only light/colors/shapes, eyes do not appear to follow objects; -[DIAGNOSES REDACTED]. -Weight 122 pounds (lbs.), 70 inches tall; -Required extensive assistance of one with transfers and toilet use; -Total dependence on assistance/full performance by one staff person for ambulation, locomotion, dressing, personal hygiene, and bathing. Review of Resident #2's social service progress notes, showed on 1/7/19 (no time documented) there were reports the resident made angry comments to staff. The resident said he/she was at the facility for seven years and was tired of people coming into his/her room. On 4/15/19 (no time documented), the Social Service Designee (SSD) documented that the resident continued to be alert, confused, and agitated. Review of a nurse's note, dated 4/28/19 (no time documented), showed Resident #2 attempted to bite another resident, for grabbing his/her soda. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Physical behavior symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing) occurred one to three days; -Verbal behavior symptoms directed towards others (e.g. threatening, screaming, cursing) occurred one to three days, but less than daily; -Weight 223 lbs., 68 inches tall; -Required limited assistance with locomotion on unit; -Required extensive assistance with locomotion off unit; -Limited assistance with ambulation. Further review of social service progress notes, showed on 6/1/19 (no time documented), staff witnessed the resident attempt to swing on another resident. The Assistant Director of Nursing (ADON) and SSD spoke with the resident about not attempting to or hitting anyone. However, the resident was very confused. Staff would have to redirect the resident, if he/she was agitated. Review of a staff note, dated 6/1/19 (no time documented), showed Resident #2 slapped another resident across the face for no reason at all. Further review of the resident's nurse's notes, showed the following: -6/1/19 (no time documented), the resident attempted to slap another resident in the face for taking a soda from his/her table. The nurse instructed the CNAs to keep the two residents separated, while in the dining room. Staff notified social services and told the resident, if he/she continued to try to harm others, he/she would be sent out to psych. The resident had a history of [REDACTED]. He/she seemed to understand and was easily redirected; -6/2/19 (no time documented), resident was in the dining room. He/she yelled, if that m*f comes by my table again, I'm gonna get him. Staff redirected the resident to his/her room and provided a hall tray. Further review of the resident's social service progress notes, dated 7/16/19 (no time documented), showed the resident continued to have behaviors and required 24 hour care. Review of the resident's care plan, updated 8/9/19, showed the following: -Cognitive loss related to dementia; -2/26/19, emergency admit via state of Missouri, resident unable to care for self; -4/28/19, resident exhibited increased agitation; -Staff will attempt redirection, reapproach, and encourage socialization and activities to control his/her behaviors; -Resident sundowns (phenomenon in which confusion becomes worse during late afternoon, evening and night); -Resident can be grumpy, does not want people in his/her room; -Potential for alterations in behavior related to anxiety, agitation, and restlessness; -Resident gets slightly agitated at times, but is mainly calm. Review of the resident's psychiatric follow-up evaluation, dated 9/30/19, showed the chief complaint from staff was verbal aggression, yelling, hitting and biting. Review of Resident #3's behavior contract, dated 4/30/19, showed the resident had the following identified behaviors: verbal aggression toward residents and staff, history of violent outbursts (including throwing a dinner tray in the hallway), use of inappropriate language towards others, lying to staff, attempting to sneak in alcohol and over-the-counter drugs containing alcohol without a physician's orders [REDACTED]. The resident signed the contract, to signify his/her agreement to comply with changing the targeted behaviors. Refusal to comply with every part of the behavior contract would result in the resident being redirected by staff, moved back to the secured dementia and behavioral floor, as well as being sent to a psychiatric unit as needed for corrective action. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Rejection of care occurred one to three days; -Short-term memory problem; -Moderate impairment of cognitive skills for daily decision making; -[DIAGNOSES REDACTED]. -Verbal behavior symptoms directed towards others (e.g. threatening, screaming, cursing) occurred four to six days, but less than daily; -Weight 159 lbs, 71 inches tall; -Required limited assistance of one with transfers . Review of the resident's care plan, updated [DATE], showed the following: -Cognitive loss related to dementia; -Emergency admit due to the resident's caregiver abusing him/her and taking half of his/her money; -Assistance required due to confusion; -Risk for wandering from facility unattended; -Very slow ambulation via a walker with wheels; -[DATE], resident hoarding, urinating in his/her drinking cup, cursed at CNA when he/she tried to cut the resident's nails which had feces underneath them. Review of the facility abuse investigation, dated 10/11/19, showed Resident #1 was physically abused by Resident #2 and Resident #3. At approximately 4:45 A.M., the call light came on. Certified Nurse Aide (CNA) A went to answer the call light and entered the room. Resident #1 was on the floor, near the window, in the fetal position. Resident #3 and Resident #2 were hitting and kicking Resident #1. Resident #2 was bent over Resident #1 and Resident #3 was seated on the edge of the bed, close enough to kick Resident #1. CNA B helped separate the residents, while CNA A went to get Nurse C. Nurse C called 911 for Resident #1, who was in distress due to the altercation. Staff checked Resident #1's vitals and documented the following: blood pressure 56/42 (normal range: 90/[AGE] to 120/[AGE], heart rate 45 (normal range: [AGE]-100 beats per minute), pulse oximetry 78% (normal range: 95%-100%), temperature [AGE].0 (normal range: [AGE].8-99.1 degrees Fahrenheit). Resident #1 was slumped over, diaphoretic (sweating excessively), and experiencing labored breathing. According to staff, the police arrived with emergency medical services. Review of Resident #1's hospital history and physical, dated 10/11/19, showed the resident appeared to be confused and was noted to have a contusion (bruise) in the lower abdomen, abrasions to the lower legs and a contusion to the right upper arm. Resident #1 said he/she went to use the bathroom and was trying to get back to his/her room, using the wall to track and someone attacked him/her. Resident #1 tried to fight back, as best he/she could. Hospital staff was unable to evaluate his/her mental status, due to his/her language barrier and [MEDICAL CONDITION]. Radiology revealed a L1 vertebral body (portion of the spinal column which bears the weight of the upper body) fracture of indeterminate age. The resident's discharge [DIAGNOSES REDACTED]. During an interview on 10/22/19 at 1:11 P.M., CNA A said he/she provided care to Resident #1 since his/her admission to the facility. He/she was alert and oriented with confusion and did not speak too much English. Resident #1 went to the restroom independently, but got turned around and sometimes walked out into the wrong adjoining bedroom. Resident #2 was unsteady on his/her feet and sometimes fell . Consequently, CNA A went to his/her room on the night of the incident, in order to make sure he/she was not on the floor. From the doorway, CNA A saw Resident #2 and Resident #3 swinging at something on the floor. Resident #2 was standing up and Resident #3 was seated on the edge of his/her bed. CNA A entered the room and saw Resident #1 on the floor. Resident #2 was punching Resident #1 in the head and Resident #3 was kicking Resident #1 in the chest. Resident #2 was yelling, get out of my room! CNA A asked them what was going on. Resident #2 and Resident #3 yelled that Resident #1 needed to get out. One of them had activated their call light, so CNA A could not understand why they attacked Resident #1, rather than waiting for staff to come and get him/her. Resident #2 and Resident #3 were angry. CNA A physically intervened, stopping Resident #2 from hitting Resident #1. Resident #3 continued to strike Resident #1. They admitted to what they had done. Resident #2 said they had double-teamed Resident #1. Resident #3 said he/she hit Resident #1 in the face. Nurse C called the police. CNA A and CNA B got Resident #1 up off of the floor. Resident #1 was sweating so much that every thing on him/her was wet. He/she had clammy skin, a pale white face, and was breathing shallowly. CNA B was holding Resident #1, because Resident #1 was shaking. For the first time, CNA A heard Resident #1 say a sentence in English. He/she said, I'm not coming home and passed out. They thought Resident #1 was dead, because his/her jaw looked sunken in. Resident #2 and Resident #3 did not accuse Resident #1 of behaving aggressively. CNA A never saw Resident #1 behave aggressively; he/she slept all day and only left his/her room for meals. After the incident, Resident #1 was quieter, spoke very little, and barely ate. He/she used to eat 100% of his/her meals. Since the incident, when CNA A led him/her to the dining room, he/she trembled. During an interview on 10/22/19 at 1:37 P.M., CNA B said Resident #2 and Resident #3 had a problem with anyone being in their room. When a female resident would wander into their room, Resident #2 would yell, get outta here [***] ! When Resident #1 would exit the adjoining bathroom and walk into their bedroom by mistake, Resident #2 would yell at him/her. When staff reminded Resident #2 that Resident #1 was blind, Resident #2 would say, I don't give a [***] ! At around 4:00 A.M., on the morning of the incident, CNA B went to the bathroom and heard CNA A shouting, Stop it. What are you doing? CNA B went to Resident #2's and Resident #3's room. Resident #2 was standing over Resident #1, who was on the floor in a ball, using his/her hands to try and guard his/her head. Resident #2 was punching Resident #1. Resident #3, who was paralyzed on one side, was seated on his/her bed kicking Resident #1. The blows were landing on Resident #1's head. CNA B said, what are y'all doing? Resident #3 said he/she and Resident #2 double teamed Resident #1. When CNA B and CNA A got Resident #1 up off of the floor, Resident #2 and Resident #3 quieted down. Resident #2 laid down on his/her bed and Resident #3 remained seated on the side of his/her bed. Resident #1 was sweating bullets, very clammy, and breathing raggedly. He/she was very scared and appeared to be in a state of shock. They tried to help Resident #1 back to his/her room, but he/she could not make it. They sat him/her on a chair in the hallway. CNA B held Resident #1 against his/her chest. Resident #1 said, I'm not ready to go home and passed out. Since the assault, Resident #1 appeared to be having flashbacks, because he/she got very tense at mealtimes when he/she had to leave his/her room. During an interview on 10/22/19 at 4:19 P.M., Nurse C said right after the assault, Resident #1 was scared, shaky, and would not say anything. Nurse C assessed the resident and did not see any bruises. He/she had superficial scratches on his/her hand (Nurse C was unsure which hand). Nurse C called the police. During an interview on 10/29/19 at 9:52 A.M., the psychiatrist said he encouraged staff to call him any time there were behavioral incidents or concerns. Staff had contacted him a few times, regarding Resident #2's behaviors. However, the psychiatrist was unaware that those behaviors continued after his visit and medication adjustment on 9/30/19. Interventions of discussing with the resident his/her behaviors and providing verbal redirection were not effective. Due to dementia, Resident #2 lacked the mental capacity to fully comprehend everything and could not engage in reasoning. The psychiatrist could usually adjust an aggressive resident's medications, until he found a therapeutic level which prevented or minimized the degree of aggression. He was surprised by the facility's placement of Resident #2 and Resident #3 together in a room connected to Resident #1's room via a bathroom and located at the end of the hallway, which was not near the nurse's station. The assault was evidence of the risk for harm in which that arrangement placed Resident #1. It was to be expected that being assaulted and injured by two residents at the same time would be traumatic for Resident #1. He/she would likely benefit from some form of therapeutic intervention. If the facility had informed the psychiatrist that staff was having difficulty managing the behaviors of Resident #2 and Resident #3, then he would have assisted them with securing placement in a facility with a psychiatric unit. That would have been more appropriate than attempting to educate two residents with dementia, regarding their behaviors or providing verbal redirection. During an interview on 10/30/19 at 12:59 P.M., the Administrator said Resident #2 was just a grumpy old man/woman. The Administrator was aware the resident was particular about his/her room, but never heard he/she was pushing residents who wandered into it. She was aware Resident #2 swung at residents, but whether or not that would necessitate a room change or psychiatric intervention depended upon the incident and what happened. Resident #2 never appeared to be dangerous. His/her behaviors needed to be documented on his/her care plan with interventions. However, staff underwent dementia in-service training sessions, so they knew how to manage Resident #2's agitation. They knew not to come up behind him/her, not to grab his/her wheelchair, and to let him/her see what they were doing. The Administrator monitored the effectiveness of resident care plans and the Assistant Director of Nursing (ADON) filled out the behavior management forms, which updated the behavioral portions of resident care plans with newly identified issues or interventions. During an interview on 10/30/19 at 9:09 A.M., the ADON said most of Resident #2's aggression was verbal. The resident did not want people in his/her personal space and would swat at residents. He/she engaged in a couple of attempts at hitting and biting residents, after an issue with his/her knee made him/her really crabby. However, he/she was medication compliant and easy to redirect. Staff never reported to the ADON that Resident #2 was out of control or pushing residents who wandered into his/her room. She was not notified of any behavioral issues which necessitated a call to the resident's psychiatrist. Resident #1 was always going into Resident #2's room. Usually, Resident #2 shouted directions or got his/her walker and guided Resident #1 back out of the room. During an interview on 10/22/19 at 1:11 P.M., CNA A said Resident #2 sundowned in the evening, which made him/her more agitated. He/she refused to drink water and liked to drink soda all day, which seemed to contribute to his/her irritability. Resident #2 had always been aggressive. Staff had to intervene quickly, because Resident #2 was on other residents so fast. It was almost like running track. Resident #2 tended to bite and strike other residents and it was not always clear what set him/her off. He/she did not want anyone in his/her room or touching his/her belongings. Whenever a resident wandered into Resident #2's room, he/she tried to push them out. When Resident #1 wandered into Resident #2's room, staff in the hallway could hear Resident #2 yelling at Resident #1 to get out of his/her room. Usually, Resident #2 only yelled and pushed Resident #1. Resident #2 previously had a room on the other side of the unit. For some reason, the facility moved him/her onto the back hall, into the room adjoined to Resident #1's room by a shared restroom. During an interview on 10/23/19 at 1:46 P.M., the SSD said Resident #2 was basically a grumpy old man/woman. As far as she knew, his/her aggression consisted of attempts to hit people. He/she would swat at residents rolling past in their wheelchairs saying, this is my food or this is my space. He/she swatted at, but did not make physical contact with, a resident in his/her unit who tended to go around taking food off of other residents' meal trays. Staff did not notify the SSD that Resident #2 was pushing residents who wandered into his/her room. During an interview on 10/22/19 at 1:37 P.M., CNA B said in attacking Resident #1, Resident #2 did what Resident #2 had always done; react with aggression when someone upset him/her. Resident #2 slapped and tried to bite another resident for attempting to grab Resident #2's soda and food. During an interview on 10/22/19 at 4:19 P.M., Nurse C said about a month prior to the assault on Resident #1, Resident #3 moved upstairs from the first floor. There were no behavioral issues, regarding other residents entering Resident #2's room, until Resident #3 moved into the room. During an interview on 10/30/19 at 9:09 A.M., the ADON said Resident #3 mostly acted out towards staff, but was not combative. His/her behaviors included arguing, manipulating, hoarding food, urinating in his/her drinking cup, taking residents' food, as well as having open food in his/her pocket and room. Resident #3's behaviors had nothing to do with hitting people. Behavioral issues should be documented in residents' care plans. Any type of aggressive behavior or resistance to redirection should be addressed in that resident's care plan. The Administrator updated resident care plans at the quarterly meetings and in response to incidents. During an interview on 10/22/19 at 1:37 P.M., CNA B said on the night of the incident, Resident #2 was the first aggressor. Resident #3 was just doing what Resident #2 did, because Resident #3 was a follower. During an interview on 10/23/19 at 1:46 P.M., the SSD said Resident #3's graduation from the secured dementia and behavioral floor lasted only one day, due to the continuation of the behaviors identified in his/her behavior contract. Resident #3 was subsequently moved back to the second floor into Resident #2's room. Room assignments for all residents were made based on unanimous decisions reached by the department heads: the SSD, director of nursing, ADON, Administrator, therapist, and activity director during the morning meeting. They based their placement decisions on which residents they believed would get along with one another and had things in common. They thought Resident #2 and Resident #3 were a good match, because they did not socialize, participate in many activities, and liked to stay in their room watching television. They shared an adjoining restroom with Resident #1 at the end of the hall, because Resident #1 resided in the adjoining room for as long as the SSD could remember, even prior to the start of her employment at the facility. The SSD and Administrator did not typically admit aggressive residents to the facility. Resident #2 and Resident #3 were state placements. The SSD and Administrator were not made privy to all of Resident #3's behaviors and did not know that he/she was aggressive. The SSD learned about Resident #2's [MEDICAL CONDITION], after his/her admission to the facility. She was aware of Resident #2's confusion and poor decision-making. During an interview on 10/30/19 at 12:59 P.M., the Administrator said room placement decisions for residents were made based on discussions during morning stand up staff meetings. They discussed whether or not two residents got along with one another. CNAs knew more about what a resident's day-to-day behavior was like, so she checked with them before making a room assignment or change. Nurses and CNAs were encouraged to update resident care plans with any incidents or issues. However, they preferred to notify the ADON, let her fill out a sheet about it, and give the sheet to the Administrator. Resident #3 was previously on the first floor. He/she was transferred to the second floor, due to the behaviors identified in his/her behavior contract, which was a part of his/her care plan and served as a guide to staff for monitoring and managing his/her behavior. During an interview on 10/29/19 at 9:52 A.M., the psychiatrist said Resident #3 had [DIAGNOSES REDACTED]. Behavior contracts were not very effective, when a resident had dementia, due to the resulting cognitive impairment. The psychiatrist communicated with staff, in order to find a therapeutic medication level which would enable them to manage a cognitively impaired resident's aggressive behaviors. Review of the facility's policy titled Abuse Policy and Procedure revised 2019, showed the policy of the facility was to ensure protection of residents from abuse. A resident-to-resident altercation was to be reviewed as a potential situation of abuse. When investigating an allegation of abuse between residents, there should not be an automatic assumption that abuse did not occur, especially in cases where either or both residents have a cognitive impairment or mental disorder. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Abuse includes the term willful. Willful means the individual's actions were deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. Based on the presence of resident-to-resident altercations, if the facility did not evaluate the effectiveness of the interventions and staff did not provide immediate interventions to assure the safety of residents, the facility did not provide sufficient protection to prevent resident-to-resident abuse. Staff should monitor for any behaviors that may provoke a reaction from residents or others, which include but are not limited to: verbally aggressive behavior (such as screaming, cursing, bossing around/demanding, intimidating), physically aggressive behavior (such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects), wandering into others' rooms/space, sexually aggressive behaviors, taking/touching/rummaging through other's property. Resident-to-resident abuse could involve a resident who has no prior history of aggressive behaviors, since a resident's behavior could quickly escalate into an instance of abuse. MO 810 MO 825

Based on observation, interview, and record review, facility staff failed to implement ordered and care planned interventions for two residents (Resident #3 and Resident #9) identified with significant weight loss. Staff failed to provide supplements and special foods ordered by the residents' physicians to provide additional calories and nutrition for the residents. The facility census was 77. 1. Review of the facility's weight loss policy, undated, showed facility staff are directed: -Weight committee will meet each Thursday to discuss any resident with significant and/or insidious weight change; -Significant weight change is defined as five percent or more in 30 days; seven and one half percent or more in ninety days, and 10 percent or more in one hundred eighty days; -Interventions will be determined for residents with significant and/or insidious weight change; -Any resident identified at risk for nutritional deficit will be referred to the Registered Dietician (RD) for assessment and recommendations to prevent weight loss or other nutritional compromise. 2. Review of Resident #3's Minimum Data Set (MDS), a resident assessment instrument, dated 12/24/15, showed staff assessed the resident as follows: -Severe cognitive impairment; -Short and long term memory problems; -[DIAGNOSES REDACTED].>-Weighs 140 pounds; -No significant weight loss in the month and six months prior to the assessment; -Requires supervision and set up assistance for eating. Review of the facility's Registered Dietitian (RD) quarterly note, dated 2/17/16, showed the RD recommended the facility implement power potatoes (fortified mashed potatoes for starch substitute) during lunch and dinner; cheesy eggs and super cereal (fortified cereal) for breakfast; health shakes three times daily; and double portions of all meal items in addition to the fortified foods. Review of the resident's plan of care, dated 3/31/16, showed staff documented the resident experienced a significant weight loss at 180 days. Further review showed staff documented dietary interventions for food supplements to include cheesy eggs, super cereal, power potatoes, double meal portions, health shakes four times daily, weekly weights to monitor progress and RD to monitor resident. Review of the resident's monthly weights showed staff documented the resident weighed 140 pounds in March 2016 and 132 pounds in April 2016, a 5.7% decline within one month. Review of the resident's Physician order [REDACTED]. Review of the resident's MAR, dated 4/1/16 through 5/1/16, showed the physician instructed staff to provide cheesy eggs and super cereal at breakfast, power potatoes during lunch and dinner, double portions of meal items, and health shakes four times daily. Further review showed the MAR indicated [REDACTED]. Review of the resident's dietary card showed dietary staff are instructed to provide the resident cheesy eggs, super cereal, and double portions of meal items for the morning meal. Observation on 4/18/16 at 5:30 P.M., showed the resident at his/her table for dinner. Observation showed staff served the resident a tuna salad sandwich, french fries, egg rolls, and pudding. The resident did not receive power potatoes or double portions of any meal items. Observation on 4/20/16 at 8:00 A.M., showed the resident received eggs without cheese, one muffin, and oatmeal. The dietary staff did not provide the resident super cereal, eggs with cheese, or double portions of any meal items. Observation showed the resident ate all of his/her food and continued to eat out of the an empty bowl. Further observation showed staff did not offer the resident any additional food items after they removed the resident's empty meal tray. Observation on 4/20/16 from 12:15 P.M. to 12:50 P.M., showed Cook I scoop fried rice, zucchini, and squash, and placed one egg roll onto the resident's plate. The cook did not serve the resident a double portion of any meal items. Observation showed the resident ate all the food on the plate. Further observation showed staff did not offer the resident any additional food items or second helpings of any food items. Observation on 4/20/16 at 1:00 P.M., showed Certified Medication Technician (CMT) D administered the resident's afternoon medications. Further observation showed CMT D did not administer a health shake. During an interview on 4/21/16 at 1:30 P.M., Cook I said he/she is expected to check the residents' diet cards when he/she prepares the residents' meal plates. Cook I said he/she does know why he/she did not provide double portions the previous day. During an interview on 4/20/16 at 4:20 P.M., CMT D said CMT's are responsible to provide the residents' ordered health shakes and document administration of the health shakes in the Medication Administration Record [REDACTED]. CMT D said if a resident had orders for health shakes four times daily, staff should administer a health shake at the morning, afternoon, evening, and bedtime med passes or only the health shake if the resident did not have any other medications ordered for that medication pass. CMT D said he/she did not give the resident health shakes because there were no orders listed in the MAR for the resident to have health shakes. During an interview on 4/21/16 at 2:30 P.M., CNA A said he/she was familiar with the resident's dietary orders as he/she often assisted the resident at meal times. CNA A said the resident did not have current orders on the MAR for health shakes. CNA said the resident received regular meals but double portions. CNA A said the resident did not receive super cereal during breakfast or power potatoes at lunch and dinner. During an interview on 4/29/16 at 11:15 A.M., the Registered Dietician (RD) said he/she expected facility staff to serve the resident cheesy eggs and super cereal for breakfast, and substitute power potatoes for a starchy meal item at lunch and dinner. The RD said facility staff should also serve the resident double portions of each meal item. The RD said he/she expected the facility staff to give the resident health shakes as recommended. The RD said if facility staff did not follow his/her recommendations, this could cause the resident's weight to continue to decline. 3. Review of Resident #9's MDS, dated [DATE], showed staff assessed the resident as follows: -Intact cognition; -Does not refuse care; -Required set up assistance from staff at meals; -Weight loss during the lookback period. Review of the resident's recorded weights showed the resident weights as follows: -February 2016: 194.8 pounds -March 2016: 181 pounds -April 2016: 176.8 pounds Additional review showed a nine percent weight loss over three months, which is a significant weight loss. Review of the resident's physician's orders [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's plan of care, dated 02/15/16, showed the care plan did not contain the health shakes or double meat portions interventions. Review of the resident's dietary card showed staff are directed to provide a regular diet, double meat portions, super cereal, and health shakes three times a day. Observation on 04/19/16 at 9:30 A.M., showed staff administered the resident's morning medications. Observation showed staff did not administer a health shake. Observation on 04/20/16 at 8:25 A.M., showed the resident's breakfast plate contained scrambled eggs and one muffin. Observation showed the plate did not contain hot cereal, meat, or eggs with cheese or double portions of any food item. Observation on 04/20/16 at 1:00 P.M., showed the resident's lunch plate contained fried rice, zucchini squash, and an egg roll. Observation showed the plate did not contain double portions of any food item. Observation on 04/21/16 at 8:45 A.M., showed the resident's breakfast plate contained one sausage patty and one piece of french toast. Observation showed the resident's dietary card said the resident's plate should include supercereal, double portions of meat, and a health shake. Observation showed the plate did not contain supercereal or double portions of any food item. During an interview on 04/20/16 at 7:55 A.M., LPN L said the nursing staff does not have a system to notify staff which residents have weight loss. The LPN said staff notifies each other verbally of residents with weight loss and any interventions in place. The LPN also said he/she did not know if the resident had an order for [REDACTED]. During an interview on 04/20/16 at 7:55 A.M., CNA G said nursing staff pass out meal trays. The CNA said charge nurses tell the CNAs which residents have weight loss. The CNA said he/she was not sure which residents have weight loss. During an interview on 04/20/16 at 8:25 A.M., the resident said the eggs are just regular and did not contain cheese. The resident said the plate did not contain meat, and he/she does not receive double portions of any food item, including meat at any meals. The resident also said he/she does not receive hot cereal and he/she doesn't like it anyway. The resident said he/she does not receive health shakes, including premade or facility prepared shakes. 4. During an interview on 04/20/16 at 11:50 A.M., the Dietary Manager (DM) said dietary staff deliver health shakes to the nursing department, and the nursing staff are responsible to serve health shakes to residents. During an interview on 04/20/16 at 12:35 P.M., the DM said he/she is responsible to order health shakes for residents. During an interview on 04/21/16 at 9:50 A.M., the DM said the food service company delivers health shakes to the facility on Tuesdays and Fridays. The DM said the facility should not run out of health shakes for residents. The DM also said he/she is expected to update residents' diet cards with new orders, dietician recommendations, and/or weight loss interventions. The DM said the diet cards are placed on the residents' trays, and dietary staff are expected to check the residents' diet cards as they prepare the residents' plates. During an interview on 04/21/16 at 9:00 A.M., RN M said staff are expected to offer second helpings to all residents. The RN said staff are expected to offer and/or provide snacks and supplements to all residents. During an interview on 04/21/16 at 2:55 P.M., the Director of Nursing (DON) said he is not sure why ordered and care planned weight loss interventions are not provided but said there have been recent changes in the dietary department. The DON said staff are expected to ensure residents receive any ordered supplements, health shakes, and food items with their meals and snacks. The DON also said staff are expected to provide health shakes with the residents' medication pass. The DON said dietary orders health shakes weekly and the facility has not been out of health shakes. MO 971

Based on observation, interview and record review, facility staff failed to prevent the development of pressure ulcers for three residents (Residents #2, #3 and #5) out of twelve sampled residents. Furthermore, staff failed to follow the facility's policy to plan and provide interventions, as well as evaluate treatments, to promote healing for the three sampled residents' pressure ulcers. The facility census was 40. 1. Review of the facility's treatment management protocol for pressure ulcers, dated 09/01/01, showed the goals of therapy were as follows: -Treat the underlying cause; -Remove and prevent necrosis; -Provide a balance environment and insulate wound; -Provide nutritional support; -Follow protocol for prevention strategies, incontinence management, positioning and pressure reduction, nutrition and therapy. Further review of the facility's treatment management protocol for pressure ulcers directed staff to re-evaluate treatment every two weeks for effectiveness. 2. Review of the facility policy and procedure "Skin at Risk Program", undated, showed it was the policy of the facility to identify residents at risk for development of pressure ulcers upon admission to the facility, readmission, at least quarterly and with any significant change. Review showed the facility would implement interventions to ensure residents admitted to the facility without pressure ulcers did not develop pressure ulcers unless the resident's clinical condition demonstrated the ulcer was unavoidable. Further review of the policy showed the policy directed staff to perform the following general skin at risk procedures: -Complete a Braden Scale Assessment upon admission, readmission, quarterly and with significant change in condition for each resident; -Charge nurse responsible to complete the Braden Scale Assessment upon admission or readmission of the resident; -Charge nurse responsible to implement preventative measures based on the results of the Braden Scale; -Forward the completed Braden Scale Assessment to the Director of Nursing (DON), Minimum Data Set (MDS) Coordinator or designee for review; -Any resident with a Braden Scale score of 17 or below was considered at risk for development of pressure ulcers; -The MDS Coordinator or designee would be responsible for updating the Braden Scale Assessment a minimum of quarterly and with every significant change of condition. Intervention would be included into the individual care plan; - A licensed nurse would document a weekly head to toe assessment for all residents; -A treatment nurse or designee should complete the weekly skin assessment and would spread over a seven day week to ensure each resident had an assessment. -Utilize a weekly skin assessment sheet to document the weekly skin assessment and place it in a binder; -The DON or designee was responsible to complete a weekly wound report on all identified pressure ulcers, stasis ulcers and other skin conditions. 3. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, dated October 2011, showed the manual defined a stage II pressure ulcer as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. Additional review showed the manual defined a stage III pressure ulcer as full thickness tissue loss. Subcutaneous fat maybe visible but bone, tendon or muscle not exposed. Slough may be present but does not obscure the depth of tissue loss. 4. Review of Resident #2's Minimum Data System (MDS), a federally mandated assessment instrument, dated 01/04/13, showed staff assessed him/her as follows: -Severely cognitively impaired; -Required limited assistance of one staff member for bed mobility, transfers and toilet use; -Required extensive assistance for dressing, personal hygiene and bathing; -Did not resist care; -No significant weight loss; -At risk for pressure ulcers; -No unhealed pressure ulcers. Review of the resident's record showed staff did not complete a Braden scale assessment as directed in their "Skin at Risk Program" to determine the risk for skin breakdown. Review of the resident's plan of care showed staff did not develop additional interventions to prevent skin breakdown (staff assessed the resident at risk for pressure ulcers in his/her MDS). Review of the Weekly Licensed Nursing Skin Assessment, dated 01/25/13, showed staff assessed the resident's skin intact with no open areas, swelling or redness. Review of the resident's Weekly Licensed Nursing Skin Assessment, dated 01/30/13, showed staff assessed the resident's left upper thigh with a "quarter" size open area without slough (a layer or mass of dead tissue separated from surrounding living tissue). Review of the wound assessment sheet, dated "01/28/13", showed staff assessed the resident with an acquired pressure ulcer located on the upper left thigh on 01/31/13. Review showed staff measured the pressure ulcer as 2.5 centimeters (cm) by 1.0 cm. Review showed staff assessed the pressure ulcer as a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) which contained 20 percent granulation (pink-red moist tissue that fills an open wound when it starts to heal) and contained 80 percent adherent slough. Additional review showed staff assessed the pressure ulcer contained a low amount of serosanguinous (consisting of serum and blood) drainage. Review showed staff were directed to clean wound with wound cleanser, apply Santyl (an enzymatic [MEDICATION NAME] ointment), dry and cover every day and as needed. Review of the resident's physician progress notes [REDACTED]. (A stage II pressure ulcer does not have slough). Review of the resident's care plan, undated, showed staff identified the resident with impaired skin integrity with a stage II pressure ulcer to the left buttocks/thigh onset 01/31/13 and planned the following interventions to promote healing and minimize risk of further breakdown: -Utilize half rail or trapeze to assist in bed mobility or half rail for gripping to reposition self; -Assist resident to turn and reposition as needed for comfort and pressure relief, minimum every two hours; -Apply a pressure relief mattress on bed and device in wheelchair; -Prompt incontinent care as needed; -Licensed nurse to complete a weekly skin assessment; -CNA to complete a skin assessment with each shower; -Observe skin during care - check for change in temperature, integrity, color; -Assure positioned properly at all times. Educate on need to get off coccyx; -Provided treatments as ordered. Document noncompliance and consult doctor; -Educate on effects of noncompliance and benefits of compliance with treatment plans; -Resident refuses to change style of undergarments. Review of the wound assessment sheet, dated 02/04/13, showed staff assessed the resident with an acquired pressure ulcer located on the upper left thigh on 01/31/13. Review showed staff measured the pressure ulcer as 2.1 cm by 1.0 cm. Review showed staff assessed the pressure ulcer as a "stage II" pressure ulcer with a 35 percent pink wound base and 65 percent yellow wound base. Review showed staff assessed the pressure ulcer contained 35 percent granulation and 65 percent adherent slough. Additional review showed staff assessed the pressure ulcer contained a low amount of serosanguinous drainage. Review showed staff were directed to clean wound with wound cleanser, apply Santyl, dry and cover every day and as needed. Review of the facility's Weekly Wound Report, dated 02/04/13, showed staff documented a facility acquired Stage II pressure ulcer onset of 01/31/13. Review showed the staff assessed the "stage II" pressure ulcer on the resident's left upper thigh. Review showed staff assessed the pressure ulcer measured 2.1 cm in length and 0.1 cm in width. Additional review showed staff assessed the pressure ulcer 65 percent yellow slough, 35 percent pink wound bed and low amount of serosanguinous drainage. Review of the facility's Weekly Wound Report, dated 02/11/13, showed staff documented a facility acquired Stage II pressure ulcer onset of 01/31/13. Review showed the staff assessed the "stage II" pressure ulcer on the resident's left upper thigh. Review showed staff assessed the pressure ulcer measured 1.6 cm in length and 1.0 cm in width. Additional review showed staff assessed the pressure ulcer 50 percent yellow slough, 50 percent pink wound bed and low amount of serosanguinous drainage. Review of the facility's Weekly Wound Report, dated 02/18/13, showed staff documented a facility acquired Stage II pressure ulcer onset of 01/31/13. Review showed the staff assessed the "stage II" pressure ulcer on the resident's left upper thigh. Review showed staff assessed the pressure ulcer measured 2.5 cm in length and 1.0 cm in width. Additional review showed staff assessed the pressure ulcer 90 percent yellow slough, 10 percent pink wound bed and low amount of serosanguinous drainage. Review of the resident's physician progress notes [REDACTED]. Review of the wound assessment sheet, dated 02/25/13, showed staff assessed the resident with an acquired pressure ulcer located on the upper left thigh on 01/31/13. Review showed staff measured the pressure ulcer as 2.7 cm by 1.0 cm. Review showed staff assessed the pressure ulcer as a "stage II" pressure ulcer with 10 percent pink wound base and 90 percent yellow wound base. Review showed staff assessed the pressure ulcer contained zero percent granulation and 90 percent adherent slough. Additional review showed staff assessed the pressure ulcer contained a low amount of serosanguinous drainage. Review showed staff were directed to clean wound with wound cleanser, apply Santyl, dry and cover every day and as needed. Review of the facility's Weekly Wound Report, dated 02/25/13, showed staff documented a facility acquired Stage II pressure ulcer onset of 01/31/13. Review showed the staff assessed the "stage II" pressure ulcer on the resident's left upper thigh. Review showed staff assessed the pressure ulcer measured 2.7 cm in length and 1.0 cm in width. Additional review showed staff assessed the pressure ulcer 90 percent yellow slough, 10 percent pink wound bed and low amount of serosanguinous drainage. Review of the resident's plan of care showed staff updated the care plan on 02/25/13 directing staff the resident's pressure ulcer on his/her left upper thigh area measured 2.7 centimeter (cm) x 1.0 cm. Staff did not add new interventions to promote healing of the pressure ulcer. Review of the facility's Weekly Wound Report, dated 03/04/13, showed staff documented a facility acquired Stage II pressure ulcer onset of 01/31/13. Review showed the staff assessed the "stage II" pressure ulcer on the resident's left upper thigh. Review showed staff assessed the pressure ulcer measured 2.1 cm in length and 1.4 cm in width. Additional review showed staff assessed the pressure ulcer 80 percent yellow slough, 20 percent pink wound bed and low amount of serosanguinous drainage. Review of the resident's plan of care, dated 03/04/13, showed staff documented the pressure ulcer measured 2.1 cm x 0.1 cm and directed staff to apply Hydrogel twice a day. Review of the facility's Weekly Wound Report, dated 03/11/13, showed staff documented a facility acquired Stage II pressure ulcer onset of 01/31/13. Review showed the staff assessed the pressure ulcer as a "stage II" pressure ulcer on the resident's left upper thigh. Review showed staff assessed the pressure ulcer increased in size and now had depth and measured 3.0 cm in length and 1.0 cm in width 0.2 in depth. Review of the resident's plan of care, dated 03/11/13, showed staff documented the resident's pressure ulcer measured 2.9 cm x 0.4 cm. Staff documented there was Zinc Oxide at bedside and they ordered a chair cushion (40 days after onset of pressure ulcer). Review of the resident's Braden Scale (assessment tool used to predict a resident's risk for pressure ulcer development), dated 03/11/13, showed staff assessed the resident's Braden Scale Assessment score a 14 (moderate risk for pressure ulcers). Further review showed staff did not document any previous Braden Scale assessments for the resident. During an interview on 03/29/13 at 2:15 P.M., the Administrator said she could not find any documentation to show staff assessed the resident's Braden Scale before 03/11/13. Review of the resident's plan of care, dated 03/16/13, showed staff documented the resident's chair cushion arrived (45 day after onset of pressure ulcer). Review of the wound assessment sheet, dated 03/18/13, showed staff assessed the resident with an acquired pressure ulcer located on the upper left thigh on 01/31/13. Review showed staff measured the pressure ulcer as 2.4 cm by 1.2 cm by 0.2 cm. Review showed staff did not assess the stage of the pressure ulcer. Review showed staff assessed the pressure ulcer 100 percent red wound base. Additional review showed staff assessed the pressure ulcer contained serous (serum drainage) drainage. Review showed staff were directed to clean the wound with wound cleanser, apply Hydrogel, change daily and as needed. Review of the facility's Weekly Wound Report, dated 03/18/13, showed staff documented a facility acquired Stage II pressure ulcer onset of 01/31/13. Review showed the staff assessed the "stage II" pressure ulcer on the resident's left upper thigh. Review showed staff assessed the pressure ulcer measured 2.4 cm in length and 1.2 cm in width 0.2 cm in depth. Additional review showed staff assessed the pressure ulcer 5 percent yellow slough, 95 percent pink wound bed and no drainage. Review of the wound assessment sheet, dated 03/25/13, showed staff assessed the resident with an acquired pressure ulcer located on the upper left thigh on 01/31/13. Review showed staff measured the pressure ulcer as 2.5 cm by 1.0 cm by 0.3. Review showed staff assessed the pressure ulcer as a "stage II" pressure ulcer with 90 percent red wound base and 10 percent yellow wound base. Review showed staff assessed the pressure ulcer contained 90 percent granulation. Review showed staff are to clean wound with wound cleanser, apply Santyl, dry and cover with [MEDICATION NAME] (transparent medical dressing) change daily and as needed. Review of the facility's Weekly Wound Report, dated 03/25/13, showed staff documented a facility acquired Stage II pressure ulcer onset of 01/31/13. Review showed the staff assessed the "stage II" pressure ulcer on the resident's left upper thigh. Review showed staff assessed the pressure ulcer measured 2.5 cm in length and 1.0 cm in width 0.3 cm in depth. Additional review showed staff assessed the pressure ulcer 100 percent pink wound bed and no drainage. Review of the resident's Physician Order Sheet (POS), dated 03/01/13 through 03/31/13, showed the physician directed staff to: -Cleanse wound to left lower buttocks with wound cleanser , apply Santyl ointment, apply 4x4 gauze, secure with tape, change daily and as needed until healed; -[MEDICATION NAME] one packet by mouth twice daily to aid in wound healing; -Vitamin C 500 Milligrams (mg) one tablet daily; -Zinc Sulfate 220 mg. Review of the resident's Treatment Administration Record (TAR), dated 03/01/13 through 03/31/13, showed staff are directed to: -Cleanse wound to left lower buttocks with wound cleanser , apply Santyl ointment, apply 4x4 gauze, secure with tape, change daily and as needed until healed. Observation and interview on 03/27/13 at 10:32 A.M., showed the resident lay on his/her bed. Observation showed the resident upper left thigh with an approximately quarter size open area, pink tissue on the outer portion of the center and yellow slough in the center. At this time, Licensed Practical Nurse (LPN) D said the resident's pressure ulcer had yellow slough and was a stage III. However, the interim Director of Nursing (DON), also in the room, said he/she staged the pressure ulcer as a stage II. Observation on 03/26/13 at 11:45 A.M., showed the resident sat in his/her recliner. Observation on 03/27/13 at 8:15 A.M., showed the resident sat in his/her recliner. Observation on 03/28/13 at 6:48 A.M., showed the resident sat in his/her recliner. At this time the resident said he/she preferred to sit in his/her recliner. The resident said he/she did not lie down in his/her bed often. Observation on 03/9/13 at 5:19 A.M., showed the resident asleep in his/her recliner. Review of the nursing notes, dated 11/19/12 through 03/28/13, showed staff did not document educating the resident the risks of not repositioning and laying down in a bed compared to the recliner. During an interview on 03/27/13 at 3:18 P.M., the LPN D said the resident did not like to sleep in his/her bed. LPN D said the resident slept in his/her recliner. LPN D said he/she did not know why it took 40 days to order the resident a cushion for his/her recliner. LPN D said the Administrator was responsible for ordering cushions for the residents. During an interview on 03/29/13 at 5:21 A.M., Certified Nursing Assistant (CNA) N said the resident liked to sleep in his/her recliner. CNA N said he/she asked the resident to sleep in his/her bed but the resident refused. During an interview on 03/29/13 at 2:15 P.M., The Administrator said the resident sat in his/her chair "all day." The Administrator said she was responsible for ordering pressure relieving cushions. The Administrator said she did not know why it took 40 days after the onset of the pressure ulcer to order the pressure relieving cushion for the resident's recliner. 5. Review of Resident # 3's MDS, dated [DATE], showed staff assessed the resident as follows: - Moderate cognitive impairment; - Frequently incontinent of urine; - Occasionally incontinent of bowel; - Dependent on two or more staff for transfers and bathing; - Required extensive assistance of two or more staff for toileting; - Required hands on assistance of one staff for dressing, personal hygiene, and bed mobility; - Required set up assistance of one staff for eating; - At risk for pressure ulcers; - No pressure ulcers at this time; - Did not reject care. Review of the resident's Braden Scale, dated 02/12/13, showed staff assessed the resident at moderate risk for pressure ulcers. Review of the resident's Admission Nursing Assessment, dated 02/12/13, showed staff did not document any skin breakdown on readmission to the facility. Review of the resident's comprehensive plan of care, last updated on 02/20/13, showed staff planned the following: - Apply a pressure reducing cushion in wheelchair; - Licensed nurse to complete skin assessments weekly and CNAs complete skin audits on shower days; - Apply pressure relief mattress on bed; - Provide prompt incontinent care as needed; - Apply barrier cream with each incontinent episode; - Assist to turn and reposition as needed for comfort and pressure relief; minimum every two hours; - Observe skin during care - check for change in temperature, integrity, color; - Assure positioned properly at all times. Educate on need to get off coccyx. Review of the resident's Wound Assessment Sheet, dated 02/25/13, showed staff first documented a facility acquired Stage II pressure ulcer on the resident's coccyx. Review also showed staff documented 02/25/13 the onset date of the Stage II pressure ulcer on the resident's coccyx. Further review showed staff documented the pressure ulcer measured 3.0 cm in length and 0.1 cm in width, wound base 100 percent red in color and no drainage. Review of the resident's Wound Assessment Sheet, dated 02/25/13, showed staff first documented a facility acquired Stage II pressure ulcer on the resident's right upper buttock. Review also showed staff documented 02/25/13 the onset date of the Stage II pressure ulcer on the resident's right upper buttock. Further review showed staff documented the pressure ulcer measured 0.4 cm in length and 0.2 cm in width, wound base 100 percent pink and no drainage. Review of the facility's Weekly Wound Report, dated 02/25/13, showed staff documented a facility acquired Stage II pressure ulcer on the resident's coccyx. Review showed staff documented the pressure ulcer measured 3.0 cm in length and 0.1 cm in width. Staff also documented the pressure ulcer a "line shaped open area", wound base 100 percent red with no drainage. Review of the facility's Weekly Wound Report, dated 02/25/13, showed staff documented a facility acquired Stage II pressure ulcer on the resident's right upper buttock. Review showed staff documented the pressure ulcer measured 0.4 cm in length and 0.2 cm in width. Staff also documented the wound base 100 percent pink with no drainage. Review of the resident's plan of care showed staff updated the care plan with the following interventions: - 02/25/13: Onset of Stage II pressure ulcer on coccyx; 3.0 x 0.1; 100% red; No drainage; Hydrogel (keeps wound bed hydrated to promote healing) twice daily (BID) and as needed (PRN). - 02/25/13: Onset of Stage II right upper buttock; 0.4 x 0.2; Hydrogel BID and PRN; 100% red; No drainage; Physical Therapy at this time; Multivitamin with minerals. - 02/25/13: Stage II coccyx 3.0 x 0.1; Cleanse with Dermal Wound Cleanser (DWC), apply Hydrogel and a dry dressing BID and PRN for two weeks and re-evaluate. - 02/25/13: Stage II right upper buttock 0.4 x 0.2; Cleanse with DWC, apply Hydrogel and a dry dressing BID and PRN and re-evaluate in two weeks. Review of the resident's POS, dated 03/01/13 through 03/31/13, showed the physician directed staff to: - Apply barrier cream to groin and buttocks after each incontinent episode as needed; - Coccyx wound care: clean with DWC and apply zinc oxide three times daily and as needed; - [MEDICATION NAME] one packet daily to aid in wound healing; - Vitamin C 500mg one tablet daily. Review of the resident's TAR, dated 03/01/13 through 03/31/13, showed staff are directed to: - Coccyx wound care: cleanse with Dermal Wound Cleanser and apply zinc oxide three times daily and as needed after each incontinent episode. Review of the resident's Wound Assessment Sheet, dated 03/04/13, showed staff documented the resident's coccyx pressure ulcer measured 1.27 cm in length and 0.1 cm in width. Staff also documented the wound base 100 percent red with low amount of serous drainage. Review also showed staff documented the pressure ulcer as Stage II. Review of the resident's Wound Assessment Sheet, dated 03/04/13, showed staff documented the resident's right upper buttock pressure ulcer measured 0.3 cm in length and 0.2 cm in width. Staff also documented the wound base 100 percent pink with low amount of serous drainage. Review also showed staff documented the pressure ulcer as Stage II. Review of the resident's plan of care, dated 03/04/13, showed staff documented the following: -Coccyx 3.0 x 0.1; scant drainage; Hydrogel continued to Stage II; Now 1.27 x 0.1; Improved. -Stage II right buttock 0.3 x 0.2; Improved; Hydrogel continues. Review of the resident's Wound Assessment Sheet, dated 03/11/13, showed staff documented the resident's coccyx pressure ulcer measured 2.9 cm in length and 0.4 cm in width. Staff also documented the wound base 100 percent pink with no drainage. Review also showed staff documented the pressure ulcer as Stage II. Review of the resident's Wound Assessment Sheet, dated 03/11/13, showed staff documented the resident's right upper buttock pressure ulcer as healed. Review of the resident's plan of care, dated 03/11/13, showed staff documented the following: -Stage II coccyx 2.4 x 0.4; Zinc oxide (cream to protect skin from moisture) three times daily (TID); Chair cushion. -[MEDICATION NAME] one packet daily. Review of the resident's nurses' notes, dated 03/14/13, showed staff documented "pressure relief cushion ordered 03/13/13." Review of the resident's Wound Assessment Sheet, dated 03/17/13, showed staff documented the resident's coccyx pressure ulcer measured 2.0 cm in length and 0.3 cm in width. Staff also documented the wound base 100 percent pink with no drainage. Review of the resident's nurses' notes, dated 03/20/13, showed staff documented "pressure relief cushion delivered 03/19/13." Observation on 03/26/13 from 11:56 A.M. to at least 12:55 P.M. showed the resident sat in his/her wheelchair at a dining room table. Observation also showed several staff in the dining room throughout this time. Staff did not reposition the resident while he/she sat in his/her wheelchair during this time. Observation on 03/26/13 from 4:46 P.M. to at least 6:21 P.M., showed the resident sat in his/her wheelchair in the dining room. Observation also showed several staff in the dining room throughout this time. Staff did not reposition the resident in his/her wheelchair during this time. Observation on 03/27/13 from 8:11 A.M. to 8:54 A.M., showed the resident sat in his/her wheelchair in the dining room and in his/her room. Observation also showed CNA R entered the resident's room at 8:45 A.M. Observation showed staff did not reposition the resident in his/her wheelchair during this time. Observation on 03/27/13 at 8:54 A.M., showed CNA E and CNA R transferred the resident into bed with the Hoyer lift and provided incontinence care. Observation also showed the CNAs positioned the resident on his/her back after incontinence care was provided. Observation on 03/27/13 at 10:14 A.M., showed the resident lay on his/her back in bed. Observation on 03/27/13 at 10:14 A.M., showed the interim DON and LPN D entered the resident's room to provide wound care. Observation showed a narrow, linear open area on the resident's coccyx. Further observation showed the wound bed pink with no visible drainage. Observation on 03/27/13 at 2:48 P.M., showed the resident lay on his/her back in bed. Observation on 03/27/13 from 5:26 P.M. to at least 6:25 P.M., showed the resident sat in his/her wheelchair at a dining room table. Observation showed several staff in the dining room throughout this time. Staff did not reposition the resident in his/her wheelchair during this time. Observation on 03/28/13 from 5:50 A.M. to at least 8:45 A.M., showed the resident sat in his/her wheelchair in his/her room or in the dining room. Observation also showed several staff passed by the resident's room and in the dining room throughout this time. Staff did not reposition the resident in his/her wheelchair during this time. Observation on 03/28/13 at 3:02 P.M., showed the resident lay on his/her back in bed. Observation on 03/29/13 from 5:15 A.M. to at least 7:35 A.M., showed the resident sat in his/her wheelchair in his/her room and in the dining room. Observation also showed several staff passed by the resident's room and in the dining room throughout this time. Staff did not reposition the resident in his/her wheelchair during this time. Observation on 03/29/13 at 10:40 A.M., showed the resident lay on his/her back in bed. During an interview on 03/27/13 at 9:29 A.M., CNA E said staff should turn the resident every two hours, but the resident "can sit up and is more mobile" than other residents at risk for skin breakdown. During an interview on 03/27/13 at 5:03 P.M., CNA F said the resident preferred to sit in his/her wheelchair or lie on his/her back in bed but "will allow" the staff to turn him/her. During an interview on 03/27/13 at 3:40 P.M., LPN D said a physician's order was required to obtain pressure relief cushions. The LPN said need for a cushion is determined at the weekly interdisciplinary team meeting. During an interview on 03/29/13 at 9:35 A.M. LPN D said staff were expected to turn and/or reposition the resident every two hours but the resident "doesn't care to be on his/her side." The LPN said staff were expected to educate and encourge the resident regarding the need to turn and/or reposition. The LPN said staff "may forget at times" to continue to educate the resident. During an interview on 03/29/13 at 2:20 P.M., the Administrator said staff were expected to reposition residents "at minimum, every two hours." The Administrator also said she was responsible to obtain pressure relief cushions for residents. The Administrator said she "didn't know why" staff did not provide a pressure relief cushion for the resident's wheelchair until 03/19/13, three weeks after the resident developed a facility acquired Stage II pressure ulcer on his/her coccyx. 6. Review of the Resident #5's admission face sheet showed staff admitted the resident to the facility on [DATE]. Further review of the sheet showed staff readmitted the resident to the facility on [DATE]. Review of the resident's Weekly Licensed Nursing Skin Assessment sheet, dated 10/17/12, showed staff documented the resident readmitted to the facility and did not have any open areas. Further review of the resident's Weekly Licensed Nursing Skin Assessment sheets, dated 10/23/12, 11/05/12, 11/12/12, 11/19/12 and 11/26/12, showed staff documented the resident did not have any opens areas. Review of the resident's weekly wound pressure report, dated 11/19/12 through 11/20/12, showed staff documented the resident developed a facility-acquired pressure sore, on his/her coccyx, on 11/20/12. Review showed staff documented the resident's coccygeal pressure sore measured 1.2 cm x 0.5 cm x 0.0 depth and treated it with zinc oxide. Review of the resident's weekly wound pressure reports, dated 12/06/12, 12/10/12, 12/17/12, 12/24/12, showed staff documented the resident's facility-acquired coccyx pressure ulcer measured 0.8 cm x 0.5 cm x 0.0 cm. Further review of the resident's weekly wound pressure reports, dated 12/10/12 and 12/17/12, showed staff documented, "re-opened area" for the resident's coccyx pressure ulcer. Additionally, review of the resident's weekly wound pressure report, dated 12/24/12, showed staff documented "stage II" for the resident's coccyx pressure ulcer. Review of the resident's weekly wound pressure report, dated 12/31/12, showed staff documented the resident's stage II facility-acquired coccyx pressure ulcer measured 2.3 cm x 1.1 cm x 0.0 cm. Review of the resident's weekly wound pressure report, dated 01/21/13, showed staff documented the resident's facility-acquired stage II coccyx pressure ulcer measured 1.8 cm x 1.0 cm x 0.0 cm. Further review of the report showed staff documented treatment for [REDACTED]. Review of the resident's weekly wound pressure report, dated 01/28/13, showed staff documented the resident's facility acquired stage II coccyx pressure ulcer measured 1.8 cm x 1.0 cm x 0.0 cm. Further review of the report showed staff documented treatment for [REDACTED]. Review of the resident's POS, dated 02/01/13 through 02/28/13, showed the resident's physician directed staff to clean the resident's coccyx wound with wound cleanser, apply wound gel, cover with a 2 x 2 dressing and tape daily and as needed until healed. Further Review of the POS [REDACTED]. Review of the resident's TAR, dated February 2013, showed the resident's physician directed staff to cleanse the resident's coccyx area with wound cleanser, apply wound gel and cover with 2 x 2 and tape daily and as needed until healed. Further review of the resident's TAR showed the resident's physician directed staff to initiate the coccyx wound treatment on 11/21/12. Review of the resident's weekly wound pressure report, dated 02/04/13, showed staff documented the resident's facility acquired stage II coccyx pressure ulcer measured 2.4 cm x 1.2 cm x 0.0 cm. Further review of the report showed staff documented treatment for [REDACTED].

Based on observation, interview and record review, the facility failed to ensure the safety of two of three sampled residents who fell . One resident (Resident #1) sustained a fracture, a forehead laceration and multiple bruises, and one resident (Resident #2) sustained a laceration on the cheekbone and bruises as a result of falls. The census was 42. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/12/10, showed the following: -[DIAGNOSES REDACTED]. -Short and long term memory loss; -Moderate cognitive loss; -Restless with repetitive physical movements; -Extensive assistance of one person during transfers and bed mobility; -Siderails raised while in bed; -No pain in the last seven days; -Hospice. Review of the resident's most recent care plan, dated 7/12/10, showed the following: -At risk for falls and injuries due to extensive assistance needed during transfers; -Would have no unavoidable falls or injuries; -Would have extensive assistance of one staff person with a gait belt during transfers. -Raise his/her siderails while he/she lay in bed to aid with self repositioning and to define parameters. -Assist him/her with safe transfers to prevent injury and falls. -At risk for prolonged bleeding due to daily use of aspirin therapy; -Use caution when transferring to prevent bruising or excessive bleeding; -11/10, staff updated the care plan to include resident fell and fractured his/her right clavicle; -Staff should assure the resident's bed is in the lowest position. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Side rails up while he/she lay in bed; -Hydrocodone APAP (prescription strength medication to relieve moderate to severe pain) 5-325 tablet, every morning. -Hydrocodone APAP 5-325 tablet three times daily as needed (PRN) for pain. -Acetaminophen 325 milligrams (mg), two tablets four times daily PRN for pain. -Aspirin 81 mg daily. Review of the resident's hospice nurse fall risk assessment score, dated 11/16/10, showed 26 points (greater than or equal to 19 points was a very high risk). Review of the resident's Medication Administration Record (MAR) dated 11/1/10 through 11/30/10 showed on the only staff documentation the resident received Hydrocodone APAP was on 11/28/10 at 8:00 A.M. During an interview on 12/15/10 at 3:15 P.M., Certified Nurse Assistant (CNA) Q, the day shift CNA said at shift change, he/she gave report to CNA C, but did not tell CNA C, nor did CNA C ask, about care needs of the residents. CNA Q did not tell CNA C any resident specific information. The CNAs were supposed to know which residents had low beds and needed siderails and how to assist residents during transfers. CNA Q worked at the facility only four days, knew the facility had care plans, but did not look at the care plans because he/she caught on quickly. He/she decided if a resident needed siderails raised when in bed based on how stable the residents appeared when they ambulated. Review of the resident's nurse's notes, dated 11/28/10 at 8:15 P.M., showed the following: -He/she lay on his/her left side with blood pooling near his/her head, talked nonsensically and moving his/her extremities; -His/her forehead had a bruise ten centimeter (cm) in circumference, raised six cm and bleeding; -A bruised right shoulder; -A bruised left third finger; -Transferred to bed; -Unable to obtain vital signs due to the resident's constant motion. -The nurse called the physician and the physician did not order staff to send the resident to the hospital. During an interview on 12/6/10 at 3:37 P.M., CNA C said 11/28/10 was his/her third day to work as a CNA. One CNA did not come to work, leaving only two CNAs and two nurses for the evening shift. CNA C was still in orientation training. Training consisted of on the job training with other CNAs. He/she did not receive training from nurses or supervisory staff or recall signing any training orientation paperwork. He/she felt very nervous about working by him/herself on the locked unit and never worked with residents suffering from severe confusion and who were combative. Every resident was combative. At the change of shift, he/she could not recall the day shift CNA giving him/her instructions about the use of siderails or the height of the resident's bed. He/she did not know where the facility kept the care plans of the residents on the locked unit, did not ask anyone, and did not refer to them. When he/she got the resident out of bed for dinner, CNA C could not remember if the resident's siderails were raised. After 7:00 P.M., Nurse A told CNA C he/she would check in throughout the shift and help CNA C put the residents to bed. Nurse A did not check on him/her until Nurse A was paged after the resident fell from bed. The resident was combative while CNA C assisted the resident into his/her gown and adult diaper and pivoted him/her to bed. He/she did not recall if he/she used a gait belt. He/she was supposed to put the siderails up but could not recall if he/she did before leaving the resident's room. Two or three minutes later, he/she found the resident on the floor with a lot of blood on the floor from the right side of his/her forehead. CNA C ran out of the unit and could not find Nurse A, ran to the dining room and yelled for Nurse F and CNA D. Nurse F and CNA D ran to the resident's room. The three staff members put a pillow under the resident's head, but left him/her on his/her left side. When Nurse A arrived, Nurse A rolled the resident onto his/her back, told CNA C to hold the resident like that, and left to call the ambulance and physician. The resident struggled to roll back to his/her side. CNA C held the resident on his/her back. Nurse A returned with ice. CNA C confronted Nurse A for leaving CNA C unassisted on the locked unit and argued about moving the resident off the floor. CNA C did not think the resident should be moved because Nurse A did not assess the resident's range of motion. Nurse A did not say the resident's shoulder looked displaced. He/she helped Nurse A get the resident into bed, could not remember if they used a gait belt, and could not remember how he/she assisted. Nurse A cleaned the blood off the floor complaining the whole time that cleaning up blood was not his/her job. Nurse F removed CNA C from the unit and said another staff member would take CNA C's place. He/she did not know when the other staff member arrived and did not speak to Nurse A during the remainder of the evening shift. During an interview on 12/6/10 at 5:08 P.M., CNA D said on 11/28/10 on the evening shift, CNA C came off the unit yelling for help. Nurse F and CNA D ran into the unit to the resident's room. The resident lay on the bloody floor. Nurse F instructed CNA D to page the resident's charge nurse, Nurse A. Nurse F said not to move the resident. When Nurse A entered the room, CNA D went back to his/her assignment. CNA C assisted Nurse A until Nurse A dismissed him/her. Nurse F reassigned CNA C, off the locked unit, to work with CNA D. CNA G arrived toward the end of the evening shift to work on the locked unit. The facility had one less CNA working that evening shift than usual. 11/28/10 was CNA C's third day to work as a CNA and work in the facility. Nurse A assigned CNA C to work by him/herself and said Nurse A would check on him/her. According to the facility's policy, new CNAs are to work for four days with other experienced CNAs before they start working on their own. Experienced CNAs show the new CNAs how to do things, then during the next two days the experienced CNAs observe the new CNAs as they perform the tasks. CNA C should not have worked in the facility without the assistance of another staff member. At approximately 10:00 P.M., CNA D took Hospice Nurse B to the resident's room. Hospice Nurse B said "No!," when he/she saw the resident's bloody face and said the resident needed to go to the hospital. CNA D took Hospice Nurse B to Nurse A, outside the locked unit. The two nurses talked about Nurse A's earlier call to the physician and Hospice Nurse B said the resident showed signs of pain and needed pain medication. Nurse A told Hospice Nurse B, Nurse A was getting ready to leave and resident would get pain medication when he/she was ready. Hospice Nurse B went back to the resident, and asked CNA D for bandages and a hospital gown for the resident. Nurse E arrived for the night shift duty. CNA D told Nurse E to go talk to Hospice Nurse B and check on the resident. During an interview on 12/3/10 at 2:00 P.M., Nurse A said on the evening of 11/28/10, a staff member paged Nurse A to the resident's room. In the resident's room, Nurse A saw Nurse F and CNA C. Nurse A noticed CNA C did not have a gait belt with him/her or around the resident. The resident lay on his/her left side in a pool of blood next to his/her bed, on the floor. The resident's bed stood in the high position with the siderails down. Nurse A cleaned blood from the resident's wound and the bleeding stopped. Nurse A rolled the resident over onto his/her back. Nurse A left the room, called the ambulance and the physician. Nurse A told the physician the resident's shoulder looked injured and the resident had a "goose egg" on his/her head with bleeding and Nurse A stopped the bleeding. Nurse A did not describe the measurements of the laceration. The physician said not to send the resident to the hospital. Nurse A told CNA C and Nurse F to assist him/her in lifting the resident into bed. CNA C and Nurse F would not touch the resident. Nurse F said not to lift the resident back into bed because lifting him/her would injure the resident further. Nurse A told Nurse F to get ice for the resident's forehead. Nurse A told CNA C he/she needed to help transfer the resident, CNA C said Nurse F said not to move the resident. Nurse A told CNA C to help with the transfer. Nurse A and CNA C lifted the resident from the floor. Nurse A said he/she propped the resident's head with his/her hands and lifted the resident's head and uninjured shoulder with CNA C lifting the resident's legs. Nurse A said he/she had a hard time remembering and thought he/she used a gait belt around the resident's waist. He/she could not recall how he/she supported the resident's head and shoulders. Nurse A said he/she got on the floor with his/her body under the resident's body to try to lift the resident. Nurse A did not perform a range of motion assessment of the resident's extremities prior to lifting the resident from the floor. Nurse A said he/she could tell something was wrong with the resident's shoulder, so he/she just avoided it. The resident wiggled his/her arms and legs such that Nurse A did not think he/she needed to perform a range of motion assessment. Nurse F did not perform range of motion on the resident because the resident was under Nurse A's care. Nurse A said it was safe to move the resident because the bleeding on the resident's forehead stopped and he/she had to get the resident off the floor. After Nurse A and CNA C took the resident's bloody clothes off, they lay the resident in bed and Nurse A left the locked unit. He/she did not see a gaping laceration because the resident's hair covered his/her forehead. Nurse A did not bother the laceration. Nurse A thought maybe the laceration was two inches long, but did not know its width. Nurse A did not interview CNA C to determine what happened or ask CNA C how he/she assisted the resident prior to the time of the fall.. Nurse A did not see CNA C the rest of the shift (approximately three hours). Nurse A went back into the locked unit one time, but did not see CNA C. Nurse A said no CNA worked back there the rest of the shift. Nurse A said he/she was in charge of CNA C and in charge of the care of all the residents on the locked unit. Nurse A did not try to find a CNA to work on the locked unit. It was CNA C's responsibility to tell Nurse A if CNA C left the locked unit. The resident's bed should have been in the lowest position. The resident had severe dementia and required two people to provide total assistance with activities of daily living. At the beginning of the evening shift, Nurse A assigned CNA C to work alone on the locked dementia unit and told CNA C the resident needed his/her siderails up when in bed. He/she did not remember telling CNA C the resident required two people to assist him/her with all activities of daily living. Nurse A did not know about the resident's transfer needs. CNA C was new to the facility, straight out of school and had no clinical experience. Four nursing staff worked that shift. CNA C was responsible for the care of the six residents on the locked unit. CNA D was responsible for the remainder of the 42 residents. The two nurses helped the CNAs when they could. The facility did not have enough staff that evening. Nurse A notified Hospice Nurse B of the resident's injuries. Hospice Nurse B visited the resident that evening, then talked to Nurse A at the nurse's station outside the locked unit. Hospice Nurse B angrily asked Nurse A how he/she could leave the resident like that and where were the other staff. Nurse A told Hospice Nurse B the resident was resting and showed no signs or symptoms of pain. Hospice Nurse B told Nurse A the resident needed butterfly stitches (thin adhesive strips used to close small wounds) on his/her laceration and needed pain medication. Nurse A said he/she gave the resident pain medication at 7:30 P.M. prior to the accident and the resident could not have any more. Nurse A gave the resident a Hydrocodone APAP tablet approximately one and one half hours after the hospice nurse arrived. During an interview on 12/6/10 at 4:46 P.M., Nurse F said on the evening of 11/28/10, CNA C came off the locked unit and yelled for help. CNA D and Nurse F found the resident on the floor. CNA C said he/she did not put the siderails up on the resident's bed. Nurse F did not know CNA C, and did not know CNA C only worked as a CNA two days prior to the resident's fall. Nurse A made the decision to place CNA C on the locked unit. Nurse A should have been on the locked unit overseeing CNA C. Review of the resident's Interdisciplinary Hospice Communication, dated 11/28/10 at 9:02 P.M., showed the following: -Nurse A called Hospice Nurse B, and reported the resident fell out of bed and had a goose egg which stopped bleeding. The physician did not order the resident sent to the hospital because the resident was on hospice. -Hospice Nurse B reviewed the facility nurse's notes, which showed the resident fell at 7:15 P.M.; -At 10:11 P.M., Hospice Nurse B assessed the resident: -Lay naked under a top sheet, in his/her bed, on his/her left side; -Had a large abrasion and bruised bump with an approximate half inch open laceration oozing blood on his/her forehead, and grimaced when Hospice Nurse B touched his/her forehead; -Had a dark purple bruise on his/her right shoulder and grimaced showing increased pain when Hospice Nurse B lifted or moved the resident's arm; -Had a bruise on his/her right knee; -Had a one inch skin tear on his/her left pinky knuckle and an intact skin tear on the back of his/her left upper arm. -Nurse A said the physician denied sending the resident to the hospital. Nurse A did not give the resident any pain medication since the resident fell . He/she would give the resident pain medication after the change of shift (11:00 P.M.). Hospice Nurse B asked a second time for pain medication for the resident. Nurse A said, "Look..., I've been here for 16 hours, I'm tired and I want to go home." Hospice Nurse B told Nurse A the resident was in pain. Nurse A said, "Don't talk to me." Hospice Nurse B left Nurse A. Nurse E arrived and assessed the resident's laceration, agreed with Hospice Nurse B the resident needed sutures, and called the physician who ordered staff to send the resident to the hospital. Nurse A gave the resident pain medication, and told Hospice Nurse B, "this was my problem, everything was fine until (Hospice Nurse B) arrived." During an interview on 12/6/10 at 12:21 P.M., Hospice Nurse B said Nurse A's nurse's notes showed the resident fell at 7:15 P.M. Nurse A did not call Hospice Nurse B until 9:00 P.M. and said the resident had a "goose egg" on his/her forehead and a bruised shoulder. Hospice Nurse B was "horrified" on 11/28/10 at 10:10 P.M., when he/she arrived at the resident's bedside. The resident had active bleeding streaming down his/her forehead from a laceration on a large contusion on the right side of his/her forehead with bloody ice packs next to the back of his/her head. The resident's limbs were drawn up. He/she shivered, naked in bed on his/her left side, cold to the touch, with repetitive, involuntary movements, holding his/her displaced shoulder forward, and covered by a sheet. The resident cried and grimaced with touch to his/her forehead and shoulder. Hospice Nurse B found Nurse A at the nurse's station. Nurse A said the physician would not give an order to send the resident to the hospital. Nurse A left the resident stable and resting, and would not tell Hospice Nurse B if he/she gave the resident pain medication, but said he/she would give the resident pain medication in a few minutes. Hospice Nurse B dressed the resident's laceration. A CNA helped Hospice Nurse B put a gown and a blanket on the resident. Not until night shift Nurse E arrived at 10:40 P.M., assessed the resident's injuries and described the extent of the laceration to the physician, did the facility get an order to send the resident to the hospital. Review of the resident's MAR, dated 11/28/10, showed the following: -Nurse A documented he/she administered a PRN Hydrocodone APAP at 10:00 P.M. Staff did not record doses given prior to 10:00 P.M. -Staff did not record the resident received Acetaminophen. Review of the resident's nurse's notes, showed the following: -11/28/10: -10:40 P.M., an unknown person asked Nurse E to assess the resident's injuries. The resident had a large bruise and half inch laceration above his/her right eye with uncontrolled bleeding, a dark bruise on his/her right shoulder and a one inch skin tear on his/her left pinky finger. Hospice Nurse B requested Nurse E call the physician, who ordered staff to send the resident to the hospital; -11/29/10: -12:00 A.M., the ambulance arrived to transport the resident whose laceration still bled uncontrollably. -2:45 A.M., the resident returned to the facility with a [DIAGNOSES REDACTED]. During an interview on 12/8/10 at 10:32 A.M., Nurse E said Hospice Nurse B asked for his/her assessment. Nurse E thought the resident needed stitches. CNA C said he/she did not put up the siderails on the resident's bed, he/she had little knowledge about the residents, never worked with residents with dementia and should have had further orientation prior to working by alone. Nurse E said the facility policy for orienting new nursing staff is new staff work with other nursing staff for three days prior to working by themselves. CNA C should not have worked by him/herself. Nurse A should have assigned another CNA to work with him/her. Observation on 11/30/10 at 12:30 P.M., showed the following: -The right side of the resident's forehead with an approximate three to four inch by one and a half inch scabbed, black area; -Both of the resident's eyes black with the right eye worse than the left; -The left middle to upper part of his/her arm with an approximate four inch by four inch triangle-shaped purple bruise; -The back of the resident's right shoulder with a large purple bruise extending approximately two inches from the bottom of his/her neck down to his/her shoulder and around to the outside of his/her shoulder; -The resident's right forearm with three bruises and a dressing above his/her right outer elbow; -Thin adhesive strips on a one inch skin tear on his/her left pinky knuckle and red and purple bruising on his/her left pinky and ring fingers extending approximately three inches past his/her wrist. Review of the facility's undated Gait Belt Policy, showed it is the policy of the facility that gait belts will be used for all resident transfers to ensure safety of the residents. Review of employee records showed on 9/24/10 Nurse A and on 11/16/10 CNA C signed the facility's gait belt policy acknowledging their orientation. Review of the facility's undated Employee Safety Rules, showed all resident lifting and transfer will be done by two employees who have demonstrated the knowledge and ability of lifting techniques to the Director of Nurses (DON) and charge nurse. Review of the facility's undated Procedure for when the Alarm Sounds policy, showed the unit must never be left unattended. If staff have an emergency, use the phone to contact someone overhead. If you leave the unit unattended you will be terminated. During an interview on 12/3/10 at 3:28 P.M., the resident's physician said on 11/28/10 in the evening, the first nurse (Nurse A) did not tell him the resident had anything more than a cut on his/her head, with bruising, Nurse A did a neurological check and applied ice to the cut. It sounded superficial. He did not recall Nurse A asking him about pain medication. He expected Nurse A to assess the resident's injuries, including performing range of motion, the size and description of the laceration, and the bruising to the resident's forehead and to give the physician an accurate description of the laceration and bruising to the resident's forehead. The second nurse, he thought a hospice nurse (Hospice Nurse B) called and insisted the resident be evaluated at the hospital due to the severity of the head injury. The nurse described the cut as "a big gash." The physician realized the resident might have head trauma, needed to be evaluated at the hospital, and needed the laceration treated. He gave the order to send the resident to the hospital. During interviews on 11/30/10 at 12:00 P.M. and on 12//14/10 at 11:50 A.M., the Assistant Director of Nurses (ADON) said the facility terminated CNA C, then inserviced nursing staff to read resident care plans and ask nurses for clarification if they were unsure how to care for a resident. The facility terminated Nurse A because he/she did not monitor the locked unit or check on the new CNA, who had never worked on the locked unit. Prior to 11/28/10, the care plans for the residents on the locked unit were outside of the locked unit at the nurse's station, and were not easily accessible to staff on the locked unit. During interviews on 12/13/10 at 10:30 A.M. and on 12/14/10 at 11:30 A.M., the DON said Nurse A should not have waited three hours before giving the resident pain relieving medication, should have assessed the resident's range of motion and should have given the physician an accurate description of the laceration and bruising to the resident's forehead. During orientation, the DON expected training of new staff to include the staff member assigned to the locked unit must stay on the locked unit at all times, and if that staff member needed to leave the unit, the DON expected him/her to use the telephone on the unit to get a replacement. CNA C should not have left the unit. The DON said Nurse A told her he/she would keep an eye on CNA C and the DON told Nurse A "okay." She expected Nurse A and CNA Q, the dayshift CNA on the locked unit, to orient CNA C to the needs of the resident, but did not know if they did, or if Nurse A kept an eye on CNA C. She expected CNAs to look at the residents' care plans to know how to care for the residents and ask the charge nurse if unsure about the resident's needs. If a resident's care plan instructed staff that the resident needed "extensive assistance of one person" during transfers, she expected staff to use a stand up lift when transferring the resident. If a resident fell and was bleeding, she expected the nurse to assess the resident's injuries, which would include describing the size of the wound, assessing for head injury and assessing the resident's range of motion prior to transferring the resident. She expected the staff to log roll the resident onto a sheet to lift the resident onto the bed. Since the resident took aspirin daily, she expected Nurse A to monitor the resident for bleeding throughout his/her shift. During an interview on 12/14/10 at 2:15 P.M., the Administrator said she expected: -Staff not to leave the residents on the locked unit unattended. The charge nurses would assign relief at break time. If a CNA needed to get help while on the unit, the CNA would just have to open the door and holler. -Staff should refer to care plans for instructions to provide specific care needs to individual residents. The facility kept the care plans at the nurse's stations outside the locked unit. She did not know how the CNA on the locked unit could get to the care plans to read instructions regarding individual residents. The facility needed to fix that. The phrase in the resident's care plan, "Extensive assistance of one person for transfers" covered a "very large gap." If she read that care plan she would have a gait belt. -At the beginning of each shift, the outgoing nurses and CNAs are to give a verbal report to oncoming CNAs. -CNA C to ask someone about the resident's siderails. CNA C should have put the siderails up, before he/she left the resident, then he/she could have gone to ask someone if the siderails should be up or down. She did not know CNA C and did not know if CNA C was qualified to be on the unit without supervision. -Nursing staff to always use a gait belt when transferring a resident. -A nurse to do a full head to toe assessment including range of motion, pain, bleeding and injuries after a resident fell . She expected the nurse to assess the resident's range of motion prior to lifting the resident. If a resident bled as a result of a fall, especially if the resident hit his/her head, she expected the nurse to monitor the resident frequently, which meant more than once per shift. -The nurse to call the physician after a resident fell and report an accurate description on the resident's injuries and assessed pain, and ask the physician about pain medication. It was not acceptable for Nurse A to wait three hours before giving the resident pain medication. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short and long term memory loss; -Moderate cognitive loss; -Sometimes understood and sometimes understands; -Extensive assistance of one person with dressing; -Assistance of one person for ambulation and transfers; -He/she wandered; -Limited range of motion and voluntary movement of both legs; -Unsteady gait; -No pain in the last seven days. Review of the resident's care plan, dated 8/10, showed the following: -Impaired cognition, and difficult to accurately assess due to language barrier, staff sometimes understood him/her and he/she sometimes understood; -Observe body language and facial expressions to assist with communication; -Attempt to obtain short phrases or words from family the resident may respond to; -Anticipate uncommunicated needs and assist; -Required extensive assistance with dressing due to dementia; -Allow resident to care for him/herself as much as possible; -Make sure tasks are completed accurately; -Observe gait frequently; -Assist as needed with dressing in seasonally appropriate clothing; -Potential for falls and injury due to dementia and an unsteady gait; - Assure he/she use a wheeled walker; -Observe gait; -Keep environment free of clutter. Review of the resident's nurse's notes, dated 11/10/10, showed the following: -1:25 P.M., CNA (CNA S) saw the resident walking independently with his/her walker, trying to pull his/her pants up, losing his/her balance, falling and landing on the floor with his/her pants down and his/her body on top of the walker; -Nurse R responded to a page to the resident and found him/her face down on the floor with his/her eyes wide open and unresponsive for three to five seconds, with a laceration (no measurements) on his/her right cheek, under his/her eye and above his/her lip; -The physician ordered staff to send the resident to the hospital; -5:20 P.M.: -A hospital emergency room nurse reported the resident had a facial fracture which will not be repaired, staples in his/her cheek and to his/her lip laceration. During interviews on 11/18/10 at 1:30 P.M. and at 2:55 P.M., CNA S said after lunch on 11/10/10, he/she saw the resident walk with his/her wheeled walker when his/her pants went down. The resident tried to pull them up and then fell over his/her walker. The resident lost weight and his/her pants were too big. The resident lived at the facility for years, lost weight over time, but had the same clothes as always. The CNAs rolled the waist band down, like teenagers wear them, to keep the pants from falling down. During an interview on 11/18/10 at 1:35 P.M., CNA Q said he/she did not see the resident fall, but was angered because the resident fell . The facility knew before the accident the resident needed smaller pants. During an interview on 11/18/10 at 1:38 P.M., CNA T said after lunch on 11/10/10, he/she saw the resident's pants falling down, and the resident went straight down. Both CNAs were too far away to assist the resident to keep him/her from falling. Review of the resident's care plan, dated 8/10, and updated on 11/10/10, showed the following: -His/her pants fell down, he/she tripped and fell resulting in a facial fracture; -Make sure clothing fits properly when assisting with dressing; -Notify the social services worker of the resident's clothing needs. Review of the physician's orders [REDACTED]. -May crush, open or dissolve appropriate medications, mechanical soft diet; -No standing order for routine or PRN pain medications; -11/10/10, (no time recorded), a telephone order to send the resident to the hospital for evaluation and treatment; Review of the resident's nurse's notes, dated 11/10/10 at 6:35 P.M., showed he/she returned from the hospital, Nurse V's report from the hospital nurse showed no instructions to provide pain medication and the resident's physician gave no orders for pain medication. Review of the resident's hospital records, dated 11/10/10 at 5:08 P.M., showed the care instructions included the resident may use Tylenol, Motrin or Advil (pain relieving medications) unless another pain medication was prescribed. The hospital attending physician ordered no prescriptions. Review of the resident's MAR, dated 11/1/10 through 11/30/10, showed the following: -11/10/10, staff did not document administration of pain medication; -11/11/10, staff did not document administration of pain medication. Review of the physician's orders [REDACTED]. -11/11/10, (no time recorded), the physician ordered Tylenol #3 one tablet every four hours PRN for pain. Review of the resident's nurse's notes, dated 11/11/10, showed the following: -6:00 A.M., he/she had a quiet night, no signs and symptoms of pain, several staples appeared loosened from the resident rubbing his/her eye, nine staples in his/her right cheek and one staple in his/her right upper lip. No further notes until 1:30 P.M. -1:30 P.M., showed Nurse R called the physician who ordered Tylenol #3 one tablet every four hours PRN for pain. Review of the resident's MAR, showed on 11/12/10 at 12:00 A.M., staff administered Tylenol #3 by mouth PRN (the first staff documentation he/she received pain relieving medication since returning from